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General NPI Number Information
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NPI Number | 1871163261
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Entity Type | Organization
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Legal Business Name | MOMENTOM WELLNESS LLC
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Dates
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Enumeration Date | 06/28/2021
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Last Update Date | 12/27/2021
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Provider Practice Location Address
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Address Line | 1336 MAIN ST
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City | OSTERVILLE
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State | MA
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Zip | 02655-1542
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Country | US
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Telephone | 508-237-5886
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Fax |
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Provider Business Mailing Address
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Address Line | 955 MAIN ST
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City | OSTERVILLE
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State | MA
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Zip | 02655-2031
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Country | US
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Telephone | 508-237-5886
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Fax |
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Authorized Official
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Title or Position | OWNER/SOLE MEMBER
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Name | DIANE OFRIA
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Credential | MS, RN, FPMHNP-BC
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Telephone | 508-237-5886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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