Provider Demographics
NPI:1659074276
Name:BANDB1 LLC
Entity Type:Organization
Organization Name:BANDB1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-501-9110
Mailing Address - Street 1:24492 HARBOUR VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2150
Mailing Address - Country:US
Mailing Address - Phone:773-501-9110
Mailing Address - Fax:
Practice Address - Street 1:4870 BIG ISLAND DR STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-5300
Practice Address - Country:US
Practice Address - Phone:773-501-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty