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NPI Code Detail

MEDICARE: KEVIN DARREL SLACK

MEDICARE: KEVIN DARREL SLACK
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
1171M00000XCase Manager/Care Coordinator

General Provider Information

NPI Number : 1508158007
Entity Type Code : Individual
Provider Name (Legal Business Name) : KEVIN DARREL SLACK
Provider Business Mailing Address
First Line : 716 S OAKWOOD AVE
Second Line :
City : BRANDON
State : FL
Zip : 33511-6124
Country : US
Telephone Number : 813-651-3150
Fax Number :
Provider Business Practice Location Address
First Line : 716 S OAKWOOD AVE
Second Line :
City : BRANDON
State : FL
Zip : 33511-6124
Country : US
Telephone Number : 813-651-3150
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2011
Last Update Date : 05/03/2011

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Directions to “ KEVIN DARREL SLACK ” Practice Location

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