Provider Demographics
NPI:1114952231
Name:FORTANASCE & ASSOCIATES SPORTS MEDICINE AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FORTANASCE & ASSOCIATES SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORTANASCE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:626-446-7027
Mailing Address - Street 1:671 NAOMI AVENUE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007
Mailing Address - Country:US
Mailing Address - Phone:626-446-7027
Mailing Address - Fax:626-446-4723
Practice Address - Street 1:1275 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750
Practice Address - Country:US
Practice Address - Phone:909-593-1200
Practice Address - Fax:909-593-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15969Medicare ID - Type Unspecified