Provider Demographics
NPI:1508158007
Name:SLACK, KEVIN DARREL
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DARREL
Last Name:SLACK
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 1:716 S OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6124
Mailing Address - Country:US
Mailing Address - Phone:813-651-3150
Mailing Address - Fax:
Practice Address - Street 1:716 S OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6124
Practice Address - Country:US
Practice Address - Phone:813-651-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator