Provider Demographics
NPI:1760547467
Name:MOMENTUM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MOMENTUM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-721-2955
Mailing Address - Street 1:11500 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1524
Mailing Address - Country:US
Mailing Address - Phone:310-721-2955
Mailing Address - Fax:
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:310-721-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty