Healthcare Provider Details

I. General information

NPI: 1730627175
Provider Name (Legal Business Name): FORTUNA MEDICAL GROUP PHYSICAL THERAPY & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11510 S FORTUNA RD SUITE A
YUMA AZ
85367-7886
US

IV. Provider business mailing address

11510 S FORTUNA RD SUITE A
YUMA AZ
85367-7886
US

V. Phone/Fax

Practice location:
  • Phone: 928-342-7046
  • Fax: 928-342-7018
Mailing address:
  • Phone: 928-342-7046
  • Fax: 928-342-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number158
License Number StateAZ

VIII. Authorized Official

Name: MR. OSWALD LOPEZ
Title or Position: PRESIDENT
Credential: OSWALD LOPEZ
Phone: 928-342-7046