Provider Demographics
NPI:1194988063
Name:MONTELONGO, OCTAVIO
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:MONTELONGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 COMERCIANTES BLVD APT 106
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9636
Mailing Address - Country:US
Mailing Address - Phone:915-313-2323
Mailing Address - Fax:
Practice Address - Street 1:105 COMERCIANTES BLVD APT 106
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9636
Practice Address - Country:US
Practice Address - Phone:915-313-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator