Provider Demographics
NPI:1831878271
Name:SLACK, JEFFREY LOUIS
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LOUIS
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 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-306-5427
Practice Address - Street 1:3608 STEVE MCQUEEN DR
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5455
Practice Address - Country:US
Practice Address - Phone:909-628-1217
Practice Address - Fax:909-306-5427
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program