Provider Demographics
NPI:1497005243
Name:MOMENTUM PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MOMENTUM PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/S&C COACH
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:EMBREE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, CSCS
Authorized Official - Phone:541-639-9770
Mailing Address - Street 1:19134 CURRIER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702
Mailing Address - Country:US
Mailing Address - Phone:541-639-9770
Mailing Address - Fax:541-919-1839
Practice Address - Street 1:19134 CURRIER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-639-9770
Practice Address - Fax:541-919-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR039322251X0800X
OR3932261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR156839Medicare PIN
OR0230952Medicaid