Healthcare Provider Details

I. General information

NPI: 1497005243
Provider Name (Legal Business Name): MOMENTUM PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19134 CURRIER DR
BEND OR
97702
US

IV. Provider business mailing address

19134 CURRIER DR
BEND OR
97702
US

V. Phone/Fax

Practice location:
  • Phone: 541-639-9770
  • Fax: 541-919-1839
Mailing address:
  • Phone: 541-639-9770
  • Fax: 541-919-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3932
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number03932
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. MELANIE ANDREA EMBREE
Title or Position: PHYSICAL THERAPIST/S&C COACH
Credential: PT, OCS, CSCS
Phone: 541-639-9770