=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548691652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOMENTUM PHYSICAL THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2013
-----------------------------------------------------
Last Update Date | 01/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4113 N FEDERAL HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-332-0501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4113 N FEDERAL HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-332-0501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WENDY YUNKER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 954-332-0501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT21553
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------