Provider Demographics
NPI:1134375967
Name:FBBB, INC.
Entity type:Organization
Organization Name:FBBB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CORDIMA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:781-393-0055
Mailing Address - Street 1:49 MYSTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4613
Mailing Address - Country:US
Mailing Address - Phone:781-393-0055
Mailing Address - Fax:781-393-0057
Practice Address - Street 1:49 MYSTIC AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4613
Practice Address - Country:US
Practice Address - Phone:781-393-0055
Practice Address - Fax:781-393-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY35201Medicare PIN