Provider Demographics
NPI:1255706966
Name:HOUSE OF BOSTIC
Entity type:Organization
Organization Name:HOUSE OF BOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER AFCH
Authorized Official - Prefix:
Authorized Official - First Name:SHALONDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTIC
Authorized Official - Suffix:
Authorized Official - Credentials:AFCH
Authorized Official - Phone:727-550-7076
Mailing Address - Street 1:1575 52ND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2629
Mailing Address - Country:US
Mailing Address - Phone:727-550-7076
Mailing Address - Fax:727-954-4227
Practice Address - Street 1:1575 52ND AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-2629
Practice Address - Country:US
Practice Address - Phone:727-550-7076
Practice Address - Fax:727-954-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906812251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health