=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376086462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM THERAPEUTICS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2016
-----------------------------------------------------
Last Update Date | 11/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 6TH AVE
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-9723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 6TH AVE
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-9723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL BRITVICH
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 724-588-3330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT019488
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------