Provider Demographics
NPI:1013113042
Name:SLAUGHTER, MARK ANTHONY SR (LVN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:SLAUGHTER
Suffix:SR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 BLAINE ST.
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:909-821-1641
Mailing Address - Fax:
Practice Address - Street 1:769 W BLAINE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3970
Practice Address - Country:US
Practice Address - Phone:951-358-4705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAVN233655164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101Y00000XBehavioral Health & Social Service ProvidersCounselor