Basic Information
| Provider Information | |||||||||
| NPI: | 1669774584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOMENTUM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3193 HAGA DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951112279 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2010 | ||||||||
| LastUpdateDate: | 11/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | ARANA | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
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| AuthorizedOfficialTitleorPosition: | COUNSELOR 11 | ||||||||
| AuthorizedOfficialTelephone: | 4089039080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.