Provider Demographics
NPI:1093912107
Name:MOMENTUM SERVICES, LLC
Entity Type:Organization
Organization Name:MOMENTUM SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-262-2183
Mailing Address - Street 1:50 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4501
Mailing Address - Country:US
Mailing Address - Phone:717-262-2183
Mailing Address - Fax:717-262-2486
Practice Address - Street 1:50 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4501
Practice Address - Country:US
Practice Address - Phone:717-262-2183
Practice Address - Fax:717-262-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 251S00000X
PA323600261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017551490004Medicaid