Healthcare Provider Details

I. General information

NPI: 1265868814
Provider Name (Legal Business Name): MOMENTUM PT & WELLNESS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2013
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2467 S 17TH ST UNIT A
WILMINGTON NC
28401-7903
US

IV. Provider business mailing address

2467 S 17TH ST UNIT A
WILMINGTON NC
28401-7903
US

V. Phone/Fax

Practice location:
  • Phone: 910-769-1238
  • Fax: 910-777-5691
Mailing address:
  • Phone: 910-769-1238
  • Fax: 910-777-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number11905
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier069KY
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS OF NC
# 2
Identifier2506019
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name: TYLER WHITESIDE
Title or Position: PRESIDENT
Credential: DPT
Phone: 703-980-5570