Healthcare Provider Details

I. General information

NPI: 1679526495
Provider Name (Legal Business Name): DR. CHARLES B SLATER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W TRACY RD
SPRING VALLEY MN
55975-1012
US

IV. Provider business mailing address

302 W TRACY RD
SPRING VALLEY MN
55975-1012
US

V. Phone/Fax

Practice location:
  • Phone: 507-346-7373
  • Fax:
Mailing address:
  • Phone: 507-346-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number037533
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: