MEDICARE: FORMFIRE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251X00000X	Supports Brokerage Agency

General Provider Information

NPI Number	:	1043630015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORMFIRE, LLC

Provider Business Mailing Address
First Line	:	1360 E 9TH ST
Second Line	:	SUITE 850
City	:	CLEVELAND
State	:	OH
Zip	:	44114-1737
Country	:	US
Telephone Number	:	216-357-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1360 E 9TH ST
Second Line	:	SUITE 850
City	:	CLEVELAND
State	:	OH
Zip	:	44114-1737
Country	:	US
Telephone Number	:	216-357-7400
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER / CEO
Name	:	MICHAEL EPP
Credential	:
Telephone Number	:	216-502-2320

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	04/17/2014

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Directions to “FORMFIRE, LLC ” Practice Location

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