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General NPI Number Information
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NPI Number | 1306722830
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Entity Type | Organization
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Legal Business Name | FORT FREEDOM, INC.
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Dates
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Enumeration Date | 08/12/2025
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 400 CHESTERFIELD PKWY
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City | MALVERN
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State | PA
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Zip | 19355-7700
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Country | US
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Telephone | 561-208-1853
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 636
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City | PORT SALERNO
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State | FL
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Zip | 34992-0636
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Country | US
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Telephone | 626-390-4080
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Fax |
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Authorized Official
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Title or Position | MARKETING DIRECTOR
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Name | MR. JONATHAN GERVASI
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Credential |
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Telephone | 626-390-4080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QV0200X
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Taxonomy Name | VA Clinic/Center
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License Number |
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License Number State |
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