Organization
MOMENTUM 180 LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DWAYNE LAMONT WILSON BS, QDDP (OWNER)
(757) 636-0884
Entity
Organization
Contact information
Practice address
739 THIMBLE SHOALS BLVD STE 503, NEWPORT NEWS, VA 23606-3562
(757) 782-4220
(757) 942-2321
Mailing address
49 RUTLAND DR, HAMPTON, VA 23666-2688
(757) 636-0884
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
Other
Enumeration date
09/09/2020
Last updated
07/14/2021
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