Provider Demographics
NPI:1568163996
Name:BROAD, JUSTIN ALLEN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALLEN
Last Name:BROAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 COLINA VISTA ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-3053
Mailing Address - Country:US
Mailing Address - Phone:330-906-0644
Mailing Address - Fax:
Practice Address - Street 1:960 COLINA VISTA ST NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3053
Practice Address - Country:US
Practice Address - Phone:330-906-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide