Organization
FORT CARE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LATEISHA NICOLE FORT APRN-FPA (CEO/PROVIDER)
(708) 668-6971
Entity
Organization
Contact information
Practice address
18241 WEST ST STE 209, LANSING, IL 60438-3200
(800) 897-4575
(800) 306-9509
Mailing address
18241 WEST ST STE 209, LANSING, IL 60438-3200
(800) 897-4575
(800) 306-9509
Taxonomy
Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
—
—
261QH0100X
Health Service Clinic/Center
Primary
—
—
291U00000X
Clinical Medical Laboratory
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14D2284487
CMS CLIA CERTIFICATE OF WAIVER
IL
01
—
248004959
DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION
IL
Enumeration date
01/31/2023
Last updated
11/03/2024
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