Provider Demographics
NPI:1396291746
Name:GARRETT, MONTRAVIOUS
Entity type:Individual
Prefix:
First Name:MONTRAVIOUS
Middle Name:
Last Name:GARRETT
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 1:2984 OSHIELDS CT SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6377
Mailing Address - Country:US
Mailing Address - Phone:770-823-5471
Mailing Address - Fax:
Practice Address - Street 1:1953 ROYAL INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-3651
Practice Address - Country:US
Practice Address - Phone:770-823-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057605326343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA46-5193426OtherEIN