Healthcare Provider Details

I. General information

NPI: 1386151645
Provider Name (Legal Business Name): FORTALEZA,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 12/02/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41641 N RIDGE RD
ELYRIA OH
44035-1264
US

IV. Provider business mailing address

41641 N RIDGE RD
ELYRIA OH
44035-1264
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-7406
  • Fax:
Mailing address:
  • Phone: 440-324-7406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY VILLA
Title or Position: CEO
Credential:
Phone: 440-324-7406