MEDICARE: LATRELL DELORES GASKIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor
2	253Z00000X	In Home Supportive Care Agency
3	372600000X	Adult Companion
4	376J00000X	Homemaker
5	251E00000X	Home Health Agency	234889	FL

General Provider Information

NPI Number	:	1891244273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATRELL DELORES GASKIN

Provider Business Mailing Address
First Line	:	3664 BRENTWOOD BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1869
Country	:	US
Telephone Number	:	904-365-3153
Fax Number	:	904-250-5902

Provider Business Practice Location Address
First Line	:	3664 BRENTWOOD BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-1869
Country	:	US
Telephone Number	:	904-365-3153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/11/2021

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