Provider Demographics
NPI:1104582246
Name:SLACK, WEBSTER DAVID JR (RN)
Entity type:Individual
Prefix:MR
First Name:WEBSTER
Middle Name:DAVID
Last Name:SLACK
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16901 NAPA ST APT 215
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91343-5653
Mailing Address - Country:US
Mailing Address - Phone:805-490-8797
Mailing Address - Fax:
Practice Address - Street 1:24790 VALLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91321-2629
Practice Address - Country:US
Practice Address - Phone:661-670-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA718243163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice