Provider Demographics
NPI:1821394545
Name:FORTAL TECH CORP
Entity Type:Organization
Organization Name:FORTAL TECH CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DULAT
Authorized Official - Middle Name:
Authorized Official - Last Name:ADILSHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-673-5619
Mailing Address - Street 1:165 CALLE MENDEZ VIGO W
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-3258
Mailing Address - Country:US
Mailing Address - Phone:787-673-5619
Mailing Address - Fax:
Practice Address - Street 1:165 CALLE MENDEZ VIGO W
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-3258
Practice Address - Country:US
Practice Address - Phone:787-673-5619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR40D2016954291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory