Provider Demographics
NPI:1629705132
Name:FORTITUDE FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FORTITUDE FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-316-3404
Mailing Address - Street 1:4423 HUNTINGTON FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-7570
Mailing Address - Country:US
Mailing Address - Phone:904-316-3404
Mailing Address - Fax:
Practice Address - Street 1:10915 BAYMEADOWS RD STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9131
Practice Address - Country:US
Practice Address - Phone:904-312-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty