Provider Demographics
NPI:1689085532
Name:BROOKSTAR KNEE CLINIC, LLC.
Entity Type:Organization
Organization Name:BROOKSTAR KNEE CLINIC, LLC.
Other - Org Name:BROOKSTAR KNEE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAILEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-668-2010
Mailing Address - Street 1:3500 HARRISON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-668-2010
Mailing Address - Fax:801-627-2228
Practice Address - Street 1:3500 HARRISON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2058
Practice Address - Country:US
Practice Address - Phone:801-668-2010
Practice Address - Fax:801-627-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168999-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty