Provider Demographics
NPI:1174178040
Name:JUSTIN C BRONDSTAD AT YOUR SERVICE LLC
Entity type:Organization
Organization Name:JUSTIN C BRONDSTAD AT YOUR SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRONDSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-451-1708
Mailing Address - Street 1:1215 W CRAMER ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1001
Mailing Address - Country:US
Mailing Address - Phone:608-451-1708
Mailing Address - Fax:
Practice Address - Street 1:1215 W CRAMER ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1001
Practice Address - Country:US
Practice Address - Phone:608-451-1708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service