Provider Demographics
NPI:1730627175
Name:FORTUNA MEDICAL GROUP PHYSICAL THERAPY & REHAB
Entity type:Organization
Organization Name:FORTUNA MEDICAL GROUP PHYSICAL THERAPY & REHAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OSWALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OSWALD LOPEZ
Authorized Official - Phone:928-342-7046
Mailing Address - Street 1:11510 S FORTUNA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-7886
Mailing Address - Country:US
Mailing Address - Phone:928-342-7046
Mailing Address - Fax:928-342-7018
Practice Address - Street 1:11510 S FORTUNA RD
Practice Address - Street 2:SUITE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7886
Practice Address - Country:US
Practice Address - Phone:928-342-7046
Practice Address - Fax:928-342-7018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORTUNA MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ142905Medicaid
AZ142905Medicaid