Healthcare Provider Details

I. General information

NPI: 1841634896
Provider Name (Legal Business Name): JUSTIN FOSTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

IV. Provider business mailing address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-9541
  • Fax: 530-273-7740
Mailing address:
  • Phone: 530-273-9541
  • Fax: 530-273-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRW7008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: