Provider Demographics
NPI:1891575924
Name:MOMENTUM DETOX LLC
Entity Type:Organization
Organization Name:MOMENTUM DETOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:N
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-800-5711
Mailing Address - Street 1:17952 BARON CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7153
Mailing Address - Country:US
Mailing Address - Phone:213-800-5711
Mailing Address - Fax:
Practice Address - Street 1:17952 BARON CIR APT 3
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7153
Practice Address - Country:US
Practice Address - Phone:213-800-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder