Provider Demographics
NPI:1104987494
Name:BST MARSHALL LLC
Entity type:Organization
Organization Name:BST MARSHALL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANDOVER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:320-839-4152
Mailing Address - Street 1:820 ROY STREET
Mailing Address - Street 2:BST MARSHALL LLC
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1138
Mailing Address - Country:US
Mailing Address - Phone:320-839-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:1420 E COLLEGE DR
Practice Address - Street 2:SUITE 704
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2075
Practice Address - Country:US
Practice Address - Phone:507-532-3393
Practice Address - Fax:320-839-4196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6154610001Medicare NSC