Healthcare Provider Details

I. General information

NPI: 1013422252
Provider Name (Legal Business Name): FSL ATX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 S LAMAR BLVD STE 100A
AUSTIN TX
78704-3964
US

IV. Provider business mailing address

2708 S LAMAR BLVD STE 100A
AUSTIN TX
78704-3964
US

V. Phone/Fax

Practice location:
  • Phone: 737-202-4214
  • Fax:
Mailing address:
  • Phone: 737-202-4214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MARANDA
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 512-221-7419