Provider Demographics
NPI:1780186825
Name:FBL ATX LLC
Entity Type:Organization
Organization Name:FBL ATX LLC
Other - Org Name:FLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-221-7419
Mailing Address - Street 1:9901 BRODIE LN STE 130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5889
Mailing Address - Country:US
Mailing Address - Phone:512-282-4271
Mailing Address - Fax:
Practice Address - Street 1:9901 BRODIE LN STE 130
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5889
Practice Address - Country:US
Practice Address - Phone:512-282-4271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental