Provider Demographics
NPI:1265868814
Name:MOMENTUM PT & WELLNESS LTD
Entity type:Organization
Organization Name:MOMENTUM PT & WELLNESS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:703-980-5570
Mailing Address - Street 1:2023 WOODWIND DR
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4146
Mailing Address - Country:US
Mailing Address - Phone:703-980-5570
Mailing Address - Fax:
Practice Address - Street 1:2023 WOODWIND DR
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4146
Practice Address - Country:US
Practice Address - Phone:703-980-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-15
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11905261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2506019OtherMEDICARE PTAN
NC069KYOtherBCBS OF NC