Provider Demographics
NPI:1750778387
Name:PAIR OF SLACKS, LLC
Entity type:Organization
Organization Name:PAIR OF SLACKS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:480-360-2299
Mailing Address - Street 1:4032 N MILLER RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4572
Mailing Address - Country:US
Mailing Address - Phone:520-248-9772
Mailing Address - Fax:
Practice Address - Street 1:4032 N MILLER RD STE 108
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-4572
Practice Address - Country:US
Practice Address - Phone:520-248-9772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAPN3104261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty