MEDICARE: JUNIOR FORBES FORTUNE P.A

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	174400000X	Specialist	PA13021	CA

General Provider Information

NPI Number	:	1891715363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUNIOR FORBES FORTUNE P.A

Provider Business Mailing Address
First Line	:	11161 CRENSHAW BLVD
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2338
Country	:	US
Telephone Number	:	310-419-1067
Fax Number	:

Provider Business Practice Location Address
First Line	:	11161 CRENSHAW BLVD
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90303-2338
Country	:	US
Telephone Number	:	310-419-1067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/09/2007

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