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General NPI Number Information
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NPI Number | 1003336181
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Entity Type | Organization
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Legal Business Name | MB PRIMARY CARE LLC
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Dates
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Enumeration Date | 06/21/2017
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Last Update Date | 06/21/2017
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Provider Practice Location Address
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Address Line | 9555 SEMINOLE BLVD STE 104
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City | SEMINOLE
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State | FL
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Zip | 33772-2522
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Country | US
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Telephone | 727-394-1500
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Fax | 866-632-1343
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Provider Business Mailing Address
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Address Line | 2213 GLENMOOR RD S
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City | CLEARWATER
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State | FL
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Zip | 33764-4922
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Country | US
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Telephone | 816-258-0431
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Fax | 866-632-1343
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Authorized Official
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Title or Position | OWNER
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Name | MELISSA MARIE BIBB
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Credential | ARNP
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Telephone | 816-258-0431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | ARNP9400491
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License Number State | FL
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