Provider Demographics
NPI:1770297178
Name:FRUIT STREET HEALTH, PBC
Entity type:Organization
Organization Name:FRUIT STREET HEALTH, PBC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-515-2417
Mailing Address - Street 1:5601 BRIDGE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2355
Mailing Address - Country:US
Mailing Address - Phone:347-647-6724
Mailing Address - Fax:888-740-2155
Practice Address - Street 1:5601 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2355
Practice Address - Country:US
Practice Address - Phone:347-647-6724
Practice Address - Fax:888-740-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty