Healthcare Provider Details

I. General information

NPI: 1831302231
Provider Name (Legal Business Name): JAMES ELLIS FORTIN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LANDIS AVE, SUITE 201
CHULA VISTA CA
91910
US

IV. Provider business mailing address

771 LAVENDER CT.
SAN MARCOS CA
92069-1958
US

V. Phone/Fax

Practice location:
  • Phone: 619-498-8450
  • Fax: 619-498-8453
Mailing address:
  • Phone: 760-798-9602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number22069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: