MEDICARE: MOMENTUMPHP CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service

General Provider Information

NPI Number	:	1356646657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMENTUMPHP CORP

Provider Business Mailing Address
First Line	:	3448 WICHITA ST.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004
Country	:	US
Telephone Number	:	713-858-9501
Fax Number	:

Provider Business Practice Location Address
First Line	:	3448 WICHITA STREET
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004
Country	:	US
Telephone Number	:	713-858-9501
Fax Number	:

Authorized Official
Title or Position	:	PRESIDING OFFICER
Name	:	WILLIAM C BULLOCK III
Credential	:	MR.
Telephone Number	:	713-858-9501

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	01/18/2011

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