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General NPI Number Information
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NPI Number | 1003504390
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Entity Type | Organization
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Legal Business Name | FORTITUDE 611 LLC
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Dates
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Enumeration Date | 04/25/2023
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Last Update Date | 04/26/2023
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Provider Practice Location Address
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Address Line | 25062 S 190TH ST
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5668
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Country | US
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Telephone | 480-329-0707
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Fax |
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Provider Business Mailing Address
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Address Line | 25062 S 190TH ST
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5668
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Country | US
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Telephone | 480-329-0707
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAIME INGRAM
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Credential |
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Telephone | 480-329-0707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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