Healthcare Provider Details

I. General information

NPI: 1841685971
Provider Name (Legal Business Name): FBLT MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 OBERLIN DR STE 301
SAN DIEGO CA
92121-4717
US

IV. Provider business mailing address

PO BOX 3881
RANCHO SANTA FE CA
92067-3881
US

V. Phone/Fax

Practice location:
  • Phone: 858-935-7745
  • Fax: 888-214-0437
Mailing address:
  • Phone: 858-935-7745
  • Fax: 888-214-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. BIRGER GREG BACINO
Title or Position: OWNER
Credential:
Phone: 858-525-5744