Provider Demographics
NPI:1386141539
Name:SLACK, STEPHEN DANIEL
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DANIEL
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 1:458 W 61ST ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-2511
Mailing Address - Country:US
Mailing Address - Phone:318-510-1141
Mailing Address - Fax:
Practice Address - Street 1:458 W 61ST ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2511
Practice Address - Country:US
Practice Address - Phone:318-510-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor