Healthcare Provider Details

I. General information

NPI: 1770475329
Provider Name (Legal Business Name): FORTIVA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13212 CHAPMAN AVE
GARDEN GROVE CA
92840-4414
US

IV. Provider business mailing address

13212 CHAPMAN AVE
GARDEN GROVE CA
92840-4414
US

V. Phone/Fax

Practice location:
  • Phone: 714-703-9492
  • Fax:
Mailing address:
  • Phone: 714-703-9492
  • Fax: 424-842-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: GREGORY GOUSHIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 856-803-6612