Healthcare Provider Details

I. General information

NPI: 1679006076
Provider Name (Legal Business Name): MICHAEL SLACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 CLEVELAND BLVD
CALDWELL ID
83605-6501
US

IV. Provider business mailing address

5111 N TRAVIS ST APT 221
SHERMAN TX
75092-4073
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-3545
  • Fax: 208-454-9690
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-1447
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberS3590
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: