Provider Demographics
NPI:1881821056
Name:FORTWOOD CENTER, INC.
Entity Type:Organization
Organization Name:FORTWOOD CENTER, INC.
Other - Org Name:MITCHELL HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN-PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-266-6751
Mailing Address - Street 1:1028 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2107
Mailing Address - Country:US
Mailing Address - Phone:423-266-6751
Mailing Address - Fax:423-763-4650
Practice Address - Street 1:1411 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2904
Practice Address - Country:US
Practice Address - Phone:423-266-6751
Practice Address - Fax:423-763-4650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENTAL HEALTH CENTERS & CLINICS OF FORTWOOD CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3399761Medicaid