Healthcare Provider Details

I. General information

NPI: 1013113042
Provider Name (Legal Business Name): MARK ANTHONY SLAUGHTER SR. LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

769 BLAINE ST.
RIVERSIDE CA
92507
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax:
Mailing address:
  • Phone: 909-821-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN233655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: