Healthcare Provider Details

I. General information

NPI: 1205755196
Provider Name (Legal Business Name): FORTABS HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S KANSAS ST
KENNEWICK WA
99336-9422
US

IV. Provider business mailing address

120 S KANSAS ST
KENNEWICK WA
99336-9422
US

V. Phone/Fax

Practice location:
  • Phone: 614-515-9284
  • Fax:
Mailing address:
  • Phone: 614-515-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: AJUSEH FORTABOH
Title or Position: OWNER
Credential:
Phone: 614-515-9284