Provider Demographics
NPI:1689457764
Name:BOSTEN, JUSTIN (BCSI, LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BOSTEN
Suffix:
Gender:M
Credentials:BCSI, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7275 COUNTY ROAD 550
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-9766
Mailing Address - Country:US
Mailing Address - Phone:906-362-3878
Mailing Address - Fax:
Practice Address - Street 1:1000 COUNTRY LN STE 400
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-3410
Practice Address - Country:US
Practice Address - Phone:906-486-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501014794225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist