Healthcare Provider Details

I. General information

NPI: 1568710945
Provider Name (Legal Business Name): MOMENTUM PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61971 KILDONAN COURT
BEND OR
97702
US

IV. Provider business mailing address

61971 KILDONAN COURT
BEND OR
97702
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number3932
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier0230952
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MRS. MELANIE ANDREA EMBREE
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 541-639-9770