Healthcare Provider Details

I. General information

NPI: 1043137862
Provider Name (Legal Business Name): JUSTIN LILL BSRT, R.T.(R)(ARRT)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 24TH AVE S STE 100
GRAND FORKS ND
58201-6761
US

IV. Provider business mailing address

4896 CHESTNUT ST
GRAND FORKS ND
58201-8014
US

V. Phone/Fax

Practice location:
  • Phone: 701-335-4380
  • Fax:
Mailing address:
  • Phone: 701-213-0463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number1057
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: