Healthcare Provider Details

I. General information

NPI: 1588599567
Provider Name (Legal Business Name): BRODAN FORTUNA CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 LAGUNA DR
SIMI VALLEY CA
93065-5303
US

IV. Provider business mailing address

688 LAGUNA DR
SIMI VALLEY CA
93065-5303
US

V. Phone/Fax

Practice location:
  • Phone: 805-207-8495
  • Fax:
Mailing address:
  • Phone: 805-207-8495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number93106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: