Healthcare Provider Details

I. General information

NPI: 1376817676
Provider Name (Legal Business Name): JUSTIN BAKAIAN RD, CNSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VA CTR
AUGUSTA ME
04330-6795
US

IV. Provider business mailing address

264 ACADEMY RD
MONMOUTH ME
04259-7033
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax:
Mailing address:
  • Phone: 207-620-2179
  • Fax: 207-753-7234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDI1080
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: