Provider Demographics
NPI:1225514888
Name:FORTITUDE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:FORTITUDE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-279-0044
Mailing Address - Street 1:5133 N CENTRAL AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1438
Mailing Address - Country:US
Mailing Address - Phone:602-279-0044
Mailing Address - Fax:602-279-0088
Practice Address - Street 1:5133 N CENTRAL AVE STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1438
Practice Address - Country:US
Practice Address - Phone:602-279-0044
Practice Address - Fax:602-279-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty