=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194328187
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRED FORTUN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2020
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23362 PERALTA DR STE 2
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92653-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-433-5115
-----------------------------------------------------
Fax | 949-713-6616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27702 CROWN VALLEY PARKWAY SUITE D-4 #230
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-433-5115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------