Provider Demographics
NPI:1023188968
Name:SLAYTER, CORDELIA ROSE (RPT)
Entity Type:Individual
Prefix:
First Name:CORDELIA
Middle Name:ROSE
Last Name:SLAYTER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2621
Mailing Address - Country:US
Mailing Address - Phone:209-223-5669
Mailing Address - Fax:209-223-4475
Practice Address - Street 1:711 S STATE HWY 49
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642
Practice Address - Country:US
Practice Address - Phone:209-223-5669
Practice Address - Fax:209-223-4475
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT139520Medicare UPIN