Provider Demographics
NPI:1154826378
Name:FPB CLINICAL PRACTICE LLC
Entity Type:Organization
Organization Name:FPB CLINICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:GROSH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:216-368-5337
Mailing Address - Street 1:2120 CORNELL ROAD NO215A
Mailing Address - Street 2:NO215A
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106
Mailing Address - Country:US
Mailing Address - Phone:216-368-5337
Mailing Address - Fax:
Practice Address - Street 1:2181 AMBLESIDE DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4645
Practice Address - Country:US
Practice Address - Phone:216-721-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service