Provider Demographics
NPI:1952558918
Name:MOMENTUM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MOMENTUM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EVANGELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-248-0248
Mailing Address - Street 1:7915 LAKE MANASSAS DRIVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:571-248-0248
Mailing Address - Fax:571-248-0250
Practice Address - Street 1:7915 LAKE MANASSAS DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:571-248-0248
Practice Address - Fax:571-248-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
VA2305204856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1188Medicare PIN