NPIMap

Organization Active NPI

Fortuna Family Medicine Inc.

  • Rural Health Clinic/Center
  • Fortuna, CA
National Provider Identifier
1508580705
Registry record updated May 29, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
FORTUNA FAMILY MEDICINE INC.
Practice address
2404 Newburg Rd
Fortuna, CA 95540-2818
Phone
(707) 617-2002
Fax
(833) 941-4882
NPI assigned
Sep 30, 2022
Last updated
May 29, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2026

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

Authorized official

Name
Nathan Dario BrinckhausNPI 1508156910
Title
MD
Phone
(707) 617-2002

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

2404 Newburg Rd
Fortuna, CA 95540-2818

Mailing address

2404 Newburg Rd
Fortuna, CA 95540-2818
Phone (707) 617-2002

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230307002112 CA Part A Provider - Rural Health Clinic 6901279264 Practice locations: Fortuna, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508580705. Details of each certification follow.

Rural health clinic certification: CCN 558910

Legal name
FORTUNA FAMILY MEDICINE INC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 12, 2023
Last certification
Sep 12, 2023
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Sep 13, 2022 in CA
Enrollment address
2404 Newburg Rd
Fortuna, CA 95540-2818

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Nathan Dario Brinckhaus Individual W-2 Managing EmployeeMD; Sep 13, 2022 100%
Randall L Bivens Individual 5% Or Greater Direct Ownership InterestSole Owner Mar 6, 2025 100%
Corporate OfficerCeo Mar 6, 2025 100%
Corporate DirectorSole Director Mar 6, 2025 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1664496000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780012800000",
    "number": "1508580705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2404 NEWBURG RD",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "955402818",
            "telephone_number": "707-617-2002",
            "fax_number": "833-941-4882"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2404 NEWBURG RD",
            "city": "FORTUNA",
            "state": "CA",
            "postal_code": "955402818",
            "telephone_number": "707-617-2002",
            "fax_number": "833-941-4882"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORTUNA FAMILY MEDICINE INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-30",
        "last_updated": "2026-05-29",
        "certification_date": "2026-05-29",
        "status": "A",
        "authorized_official_last_name": "BRINCKHAUS",
        "authorized_official_first_name": "NATHAN",
        "authorized_official_middle_name": "DARIO",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "707-617-2002"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fortuna, CA

Sources for this page

Verify at the official NPI Registry.