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General NPI Number Information
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NPI Number | 1023433604
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Entity Type | Organization
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Legal Business Name | MOMENTUM MEDICINE PLUS LLC
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Dates
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Enumeration Date | 02/19/2014
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Last Update Date | 02/19/2014
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Provider Practice Location Address
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Address Line | 113 WHITE HORSE RD W SUITE 7
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City | VOORHEES
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State | NJ
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Zip | 08043-3672
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Country | US
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Telephone | 856-552-2208
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Fax |
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Provider Business Mailing Address
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Address Line | 113 WHITE HORSE RD W SUITE 7
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City | VOORHEES
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State | NJ
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Zip | 08043-3672
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Country | US
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Telephone | 856-552-2208
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JUAN CARLOS CORNEJO
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Credential | DO
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Telephone | 856-552-2208
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 25MB08477000
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License Number State | NJ
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