Healthcare Provider Details

I. General information

NPI: 1730794603
Provider Name (Legal Business Name): MOMENTUM 180 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 07/14/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 THIMBLE SHOALS BLVD STE 503
NEWPORT NEWS VA
23606-3562
US

IV. Provider business mailing address

49 RUTLAND DR
HAMPTON VA
23666-2688
US

V. Phone/Fax

Practice location:
  • Phone: 757-782-4220
  • Fax: 757-942-2321
Mailing address:
  • Phone: 757-636-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DWAYNE LAMONT WILSON
Title or Position: OWNER
Credential: BS, QDDP
Phone: 757-636-0884