Provider Demographics
NPI:1811031578
Name:BASURTO, LETICIA A
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:A
Last Name:BASURTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-7410
Mailing Address - Country:US
Mailing Address - Phone:915-740-2687
Mailing Address - Fax:
Practice Address - Street 1:5709 LEXINGTON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-7410
Practice Address - Country:US
Practice Address - Phone:915-751-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148631311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000999813OtherSTATE I.D.