Healthcare Provider Details

I. General information

NPI: 1710519640
Provider Name (Legal Business Name): HEATHER DANIELLE BASAGOITIA CMA, CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2020
Last Update Date: 02/09/2020
Certification Date: 02/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 SW 30TH ST
FORT LAUDERDALE FL
33315-2842
US

IV. Provider business mailing address

9715 W BROWARD BLVD # 233
PLANTATION FL
33324-2351
US

V. Phone/Fax

Practice location:
  • Phone: 954-629-4309
  • Fax:
Mailing address:
  • Phone: 754-227-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number134047
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: