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General NPI Number Information
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NPI Number | 1982613717
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Entity Type | Individual
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Provider Name | CHRISTOPHER LEE SLACK M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 07/09/2010
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Provider Practice Location Address
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Address Line | 4632 S 25TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34981-5057
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Country | US
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Telephone | 772-464-9595
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Fax | 772-464-9582
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Provider Business Mailing Address
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Address Line | 4632 S 25TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34981-5057
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Country | US
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Telephone | 772-464-9595
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Fax | 772-464-9582
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | ME84369
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | 36380
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License Number State | CO
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