Provider Demographics
NPI:1942839113
Name:FORT PHYSICIANS & PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:FORT PHYSICIANS & PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER RELATIONS
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUCHINSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-544-7823
Mailing Address - Street 1:32302 ALIPAZ ST SPC 41
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4158
Mailing Address - Country:US
Mailing Address - Phone:562-544-7823
Mailing Address - Fax:949-485-6212
Practice Address - Street 1:7140 OAKMONT BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-678-7428
Practice Address - Fax:682-707-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty