| Fortitude 611 Llc | |
|
25062 S 190th St Queen Creek AZ 85142-5668 | |
| (480) 329-0707 | |
| Not Available |
| Full Name | Fortitude 611 Llc |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 25062 S 190th St, Queen Creek, Arizona |
| Authorized Official Name and Position | Jaime Ingram (OWNER) |
| Authorized Official Contact | 4803290707 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Fortitude 611 Llc 25062 S 190th St Queen Creek AZ 85142-5668 Ph: (480) 329-0707 | Fortitude 611 Llc 25062 S 190th St Queen Creek AZ 85142-5668 Ph: (480) 329-0707 |
| NPI Number | 1003504390 |
|---|---|
| Provider Enumeration Date | 04/25/2023 |
| Last Update Date | 04/26/2023 |
| Certification Date | 04/26/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003504390 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| 320800000X | Community Based Residential Treatment Facility, Mental Illness | (* (Not Available)) | Secondary |
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