Provider Demographics
NPI:1346854007
Name:FORTITUDE SPORT & SPINE
Entity Type:Organization
Organization Name:FORTITUDE SPORT & SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-449-9751
Mailing Address - Street 1:878 DANCING VINES AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6317
Mailing Address - Country:US
Mailing Address - Phone:702-449-9751
Mailing Address - Fax:
Practice Address - Street 1:878 DANCING VINES AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-6317
Practice Address - Country:US
Practice Address - Phone:702-449-9751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty