Provider Demographics
NPI:1730794603
Name:MOMENTUM 180 LLC
Entity type:Organization
Organization Name:MOMENTUM 180 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QDDP
Authorized Official - Phone:757-636-0884
Mailing Address - Street 1:49 RUTLAND DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2688
Mailing Address - Country:US
Mailing Address - Phone:757-636-0884
Mailing Address - Fax:
Practice Address - Street 1:739 THIMBLE SHOALS BLVD STE 503
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3562
Practice Address - Country:US
Practice Address - Phone:757-782-4220
Practice Address - Fax:757-942-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities