Provider Demographics
NPI:1407946965
Name:SLADE, MICHAEL DEWAYNE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEWAYNE
Last Name:SLADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 BENNINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3725
Mailing Address - Country:US
Mailing Address - Phone:757-628-4380
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:STE 1000 USCG MAINTENANCE AND LOGISTICS COMMAND ATLANTI
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510
Practice Address - Country:US
Practice Address - Phone:757-628-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other