MEDICARE: FORTWOOD CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	L000000003950	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366679409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTWOOD CENTER, INC.

Provider Business Mailing Address
First Line	:	1028 E 3RD ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37403-2107
Country	:	US
Telephone Number	:	423-266-6751
Fax Number	:	423-266-6751

Provider Business Practice Location Address
First Line	:	1508 OLD RINGGOLD RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37404-5444
Country	:	US
Telephone Number	:	423-266-6751
Fax Number	:	423-763-4650

Authorized Official
Title or Position	:	CFO
Name	:	MRS. MELISSA QUEEN-PENNINGTON
Credential	:
Telephone Number	:	423-266-6751

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/16/2009

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