Provider Demographics
NPI:1881003101
Name:HEARTHSTONE FELLOWSHIP FOUNDATION, INC
Entity Type:Organization
Organization Name:HEARTHSTONE FELLOWSHIP FOUNDATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:G
Authorized Official - Last Name:MINOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:386-238-1348
Mailing Address - Street 1:814 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2234
Mailing Address - Country:US
Mailing Address - Phone:386-238-1348
Mailing Address - Fax:386-238-0171
Practice Address - Street 1:814 N BEACH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2234
Practice Address - Country:US
Practice Address - Phone:386-238-1348
Practice Address - Fax:386-238-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0764AD071101261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder