Provider Demographics
NPI:1508083205
Name:MOMENTUM FOR HEALTH
Entity Type:Organization
Organization Name:MOMENTUM FOR HEALTH
Other - Org Name:MOMENTUM FOR HEALTH - EASTSIDE OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:MINETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:669-213-0755
Mailing Address - Street 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:438 N WHITE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-1439
Practice Address - Country:US
Practice Address - Phone:408-254-6828
Practice Address - Fax:408-642-6052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOMENTUM FOR HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-20
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008369Medicaid
ZZZ01125ZMedicare PIN