Provider Demographics
NPI:1386794543
Name:FORTUNA REHABILITATION
Entity type:Organization
Organization Name:FORTUNA REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO, COO
Authorized Official - Prefix:
Authorized Official - First Name:DONNELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:619-575-0157
Mailing Address - Street 1:2648 MAIN ST
Mailing Address - Street 2:SUITE BC
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-4664
Mailing Address - Country:US
Mailing Address - Phone:619-575-0157
Mailing Address - Fax:619-575-0053
Practice Address - Street 1:2648 MAIN ST
Practice Address - Street 2:SUITE BC
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-4664
Practice Address - Country:US
Practice Address - Phone:619-575-0157
Practice Address - Fax:619-575-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA056863261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0051200Medicaid
CAPT0051200Medicaid