Provider Demographics
NPI:1063721421
Name:FOSTER, RODERICK ANTHONY (LMT)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:ANTHONY
Last Name:FOSTER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541210
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32954-1210
Mailing Address - Country:US
Mailing Address - Phone:321-453-8484
Mailing Address - Fax:321-453-8448
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:#203
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-453-8484
Practice Address - Fax:321-453-8448
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist