Healthcare Provider Details

I. General information

NPI: 1346854007
Provider Name (Legal Business Name): FORTITUDE SPORT & SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

878 DANCING VINES AVE
LAS VEGAS NV
89183-6317
US

IV. Provider business mailing address

878 DANCING VINES AVE
LAS VEGAS NV
89183-6317
US

V. Phone/Fax

Practice location:
  • Phone: 702-449-9751
  • Fax:
Mailing address:
  • Phone: 702-449-9751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS GODFREY
Title or Position: MEDICAL DIRECTOR
Credential: DC
Phone: 702-449-9751