Provider Demographics
NPI:1013467091
Name:FORTITUDE RECOVERY LLC
Entity Type:Organization
Organization Name:FORTITUDE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-375-5959
Mailing Address - Street 1:2477 FLETCHER DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2801
Mailing Address - Country:US
Mailing Address - Phone:323-375-5959
Mailing Address - Fax:323-419-3165
Practice Address - Street 1:2477 FLETCHER DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2801
Practice Address - Country:US
Practice Address - Phone:323-375-5959
Practice Address - Fax:323-419-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0002934671-0001-4261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)