Provider Demographics
NPI:1194328187
Name:FORTUN, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:FORTUN
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 1:27702 CROWN VALLEY PARKWAY
Mailing Address - Street 2:SUITE D-4 #230
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694
Mailing Address - Country:US
Mailing Address - Phone:949-433-5115
Mailing Address - Fax:
Practice Address - Street 1:23362 PERALTA DR STE 2
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1711
Practice Address - Country:US
Practice Address - Phone:949-433-5115
Practice Address - Fax:949-713-6616
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies