Healthcare Provider Details

I. General information

NPI: 1053111054
Provider Name (Legal Business Name): SLADE ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 SHREVEPORT HWY
PINEVILLE LA
71360-4044
US

IV. Provider business mailing address

1004 HIDDEN RIDGE DR
WOODWORTH LA
71485-9529
US

V. Phone/Fax

Practice location:
  • Phone: 800-375-8387
  • Fax:
Mailing address:
  • Phone: 318-290-0913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number336500
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: