Healthcare Provider Details

I. General information

NPI: 1982613717
Provider Name (Legal Business Name): CHRISTOPHER LEE SLACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4632 S 25TH ST
FORT PIERCE FL
34981-5057
US

IV. Provider business mailing address

4632 S 25TH ST
FORT PIERCE FL
34981-5057
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-9595
  • Fax: 772-464-9582
Mailing address:
  • Phone: 772-464-9595
  • Fax: 772-464-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME84369
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number36380
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: