Provider Demographics
NPI:1437945391
Name:FORTIFY OPTIMAL HEALTH
Entity type:Organization
Organization Name:FORTIFY OPTIMAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:619-602-4520
Mailing Address - Street 1:784 SOUTH CLEAR LOOP STE R
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:619-602-4520
Mailing Address - Fax:
Practice Address - Street 1:1189 RED ROBIN AVE
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83401-5747
Practice Address - Country:US
Practice Address - Phone:619-602-4520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty