Provider Demographics
NPI:1316641418
Name:SLACK, JAMES ALLEN
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALLEN
Last Name:SLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:HANSFORD
Mailing Address - State:WV
Mailing Address - Zip Code:25103-0075
Mailing Address - Country:US
Mailing Address - Phone:304-641-1077
Mailing Address - Fax:
Practice Address - Street 1:1013 CENTER ST
Practice Address - Street 2:
Practice Address - City:HANSFORD
Practice Address - State:WV
Practice Address - Zip Code:25103
Practice Address - Country:US
Practice Address - Phone:304-610-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant