Provider Demographics
NPI:1760959548
Name:BASKIN, LESJUANTAVIUS NAJIIK (RPT)
Entity Type:Individual
Prefix:
First Name:LESJUANTAVIUS
Middle Name:NAJIIK
Last Name:BASKIN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 INDIAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2708
Mailing Address - Country:US
Mailing Address - Phone:239-222-7203
Mailing Address - Fax:
Practice Address - Street 1:2826 INDIAN ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-2708
Practice Address - Country:US
Practice Address - Phone:239-222-7203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7654321101YP1600X
FLRPT29546251E00000X, 183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RPT29546OtherHOME HEALTH