Provider Demographics
NPI:1124203666
Name:LESIN, MARTIN L (DC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:L
Last Name:LESIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5536
Mailing Address - Country:US
Mailing Address - Phone:772-335-3110
Mailing Address - Fax:772-398-0704
Practice Address - Street 1:1967 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5536
Practice Address - Country:US
Practice Address - Phone:772-335-3110
Practice Address - Fax:772-398-0704
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0002815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55715OtherBLUE CROSS BLUESHIELD FL
FL55715OtherBLUE CROSS BLUESHIELD FL