Provider Demographics
NPI:1255149704
Name:MOUNTAIN, GEORGE JR
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MOUNTAIN
Suffix:JR
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 1:1309 N 206TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6935
Mailing Address - Country:US
Mailing Address - Phone:402-312-1353
Mailing Address - Fax:
Practice Address - Street 1:1309 N 206TH ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-6935
Practice Address - Country:US
Practice Address - Phone:402-312-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor