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NPI Code Detail

MEDICARE: KELLY SLATER

MEDICARE: KELLY SLATER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1003773078
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY SLATER
Provider Business Mailing Address
First Line : 5675 W OLYMPIC BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90036-4712
Country : US
Telephone Number : 323-965-1365
Fax Number : 323-965-0444
Provider Business Practice Location Address
First Line : 5675 W OLYMPIC BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90036-4712
Country : US
Telephone Number : 323-965-1365
Fax Number : 323-965-0444
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/09/2026
Last Update Date : 01/09/2026

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Directions to “ KELLY SLATER ” Practice Location

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