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General NPI Number Information
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NPI Number | 1730794603
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Entity Type | Organization
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Legal Business Name | MOMENTUM 180 LLC
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Dates
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Enumeration Date | 09/09/2020
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Last Update Date | 07/14/2021
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Provider Practice Location Address
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Address Line | 739 THIMBLE SHOALS BLVD STE 503
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-3562
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Country | US
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Telephone | 757-782-4220
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Fax | 757-942-2321
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Provider Business Mailing Address
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Address Line | 49 RUTLAND DR
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City | HAMPTON
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State | VA
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Zip | 23666-2688
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Country | US
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Telephone | 757-636-0884
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. DWAYNE LAMONT WILSON
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Credential | BS, QDDP
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Telephone | 757-636-0884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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