Healthcare Provider Details

I. General information

NPI: 1689619124
Provider Name (Legal Business Name): CARYN KENDRA SLACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 TWIN LAKES RD
BRIDGEPORT CA
93517-8050
US

IV. Provider business mailing address

250 N SEE VEE LN
BISHOP CA
93514-8130
US

V. Phone/Fax

Practice location:
  • Phone: 530-495-2100
  • Fax: 530-495-2100
Mailing address:
  • Phone: 760-873-8464
  • Fax: 760-503-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC152597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: