Provider Demographics
NPI:1245949122
Name:FORTIN, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FORTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 4TH STREET NORTH
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102
Mailing Address - Country:US
Mailing Address - Phone:701-476-4145
Mailing Address - Fax:
Practice Address - Street 1:222 4TH STREET NORTH
Practice Address - Street 2:SUITE 3
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-476-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator