Fortitude 611 LLC

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

FORTITUDE 611 LLC

Practice address

25062 S 190TH St
Queen Creek, AZ 85142-5668

Phone

(480) 329-0707

NPI assigned

Apr 25, 2023

Last updated

Apr 26, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jaime IngramNPI 1306551122

Title

Owner

Phone

(480) 329-0707

Specialties & licenses 2

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jaime Ingram

  • Community Health Worker
  • Queen Creek, AZ
  • NPI 1306551122
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1682380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1682467200000",
    "number": "1003504390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25062 S 190TH ST",
            "city": "QUEEN CREEK",
            "state": "AZ",
            "postal_code": "851425668",
            "telephone_number": "480-329-0707"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25062 S 190TH ST",
            "city": "QUEEN CREEK",
            "state": "AZ",
            "postal_code": "851425668",
            "telephone_number": "480-329-0707"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORTITUDE 611 LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-25",
        "last_updated": "2023-04-26",
        "certification_date": "2023-04-26",
        "status": "A",
        "authorized_official_last_name": "INGRAM",
        "authorized_official_first_name": "JAIME",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "480-329-0707"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Susan Folse
• Tory Ford, FNP-C
• Carissa Kristensen Forman, PT
• Forrest Pratt DMD PLLC
• Marie Genevieve Fort
• Ashley Ann Foster, FNP
• Kimberly Ann Foster
• Cynthia Price Franco, PA-C
• Gregory Allen Fraser, RBT
• Freedom Family Chiropractic PLLC (Freedom Family Chiropractic)

• Community/Behavioral Health Agency in Queen Creek, AZ
• Providers in Queen Creek, AZ by specialty
• Community/Behavioral Health Agency in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 26, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.