Provider Demographics
NPI:1770833030
Name:SLAYTON, SIMEON CHARLES II (MS)
Entity Type:Individual
Prefix:MR
First Name:SIMEON
Middle Name:CHARLES
Last Name:SLAYTON
Suffix:II
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10519 GODWIN DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-2736
Mailing Address - Country:US
Mailing Address - Phone:703-489-9300
Mailing Address - Fax:703-530-0961
Practice Address - Street 1:10519 GODWIN DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-2736
Practice Address - Country:US
Practice Address - Phone:703-489-9300
Practice Address - Fax:703-530-0961
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705 124382332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12L24920OtherUNIQUE HOMES BUSINESS LICENSE
VA2705-124382OtherCONTRACTORS LISENCE