Provider Demographics
NPI:1114282621
Name:MOMENTUM CHIROPRACTIC AND REHAB, LLC
Entity Type:Organization
Organization Name:MOMENTUM CHIROPRACTIC AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:703-369-2559
Mailing Address - Street 1:9408 GRANT AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5511
Mailing Address - Country:US
Mailing Address - Phone:703-369-2559
Mailing Address - Fax:703-369-2733
Practice Address - Street 1:9408 GRANT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5511
Practice Address - Country:US
Practice Address - Phone:703-369-2559
Practice Address - Fax:703-369-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty