Provider Demographics
NPI:1770016347
Name:SHANTELL FOSTER
Entity Type:Organization
Organization Name:SHANTELL FOSTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTELL
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-753-3285
Mailing Address - Street 1:96159 MOUNT ZION LOOP
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6332
Mailing Address - Country:US
Mailing Address - Phone:904-753-3285
Mailing Address - Fax:904-849-7124
Practice Address - Street 1:96159 MOUNT ZION LOOP
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-6332
Practice Address - Country:US
Practice Address - Phone:904-753-3285
Practice Address - Fax:904-849-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities