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General NPI Number Information
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NPI Number | 1952797243
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Entity Type | Organization
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Legal Business Name | MOMENTUM PROSTHETIC CLINIC LLC
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Dates
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Enumeration Date | 04/13/2015
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 3817 STEPHENS AVE STE 2
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City | MISSOULA
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State | MT
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Zip | 59801-8542
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Country | US
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Telephone | 406-926-1321
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Fax | 406-926-1327
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Provider Business Mailing Address
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Address Line | 3817 STEPHENS AVE STE 2
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City | MISSOULA
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State | MT
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Zip | 59801-8505
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Country | US
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Telephone | 406-926-1321
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Fax | 406-926-1327
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Authorized Official
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Title or Position | PRACTITIONER/MANAGING MEMBER
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Name | CLIFFORD HENRY CREEKMORE
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Credential | CPO
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Telephone | 406-529-0474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 2015-MSS-GEN-00092
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License Number State | MT
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