=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265300552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMUMENTAL PHYSICAL THERAPY & PERFORMANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2025
-----------------------------------------------------
Last Update Date | 02/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 MARY ALICE PARK RD STE 601
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-239-0132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4820 WESTGATE DR
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-9447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. ALYSSA VARSALONA RIVES
-----------------------------------------------------
Credential | PT, DPT, CSCS
-----------------------------------------------------
Telephone | 404-839-1416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------