Provider Demographics
NPI:1497330765
Name:SLAUGHTER, IVAN (PTA)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SLAUGHTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6898 A C SKINNER PKWY UNIT 318
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7929
Mailing Address - Country:US
Mailing Address - Phone:904-442-3629
Mailing Address - Fax:
Practice Address - Street 1:2202 W OAK AVE
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-7222
Practice Address - Country:US
Practice Address - Phone:813-754-3761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant