Provider Demographics
NPI:1912068552
Name:SLAUGHTER, CHARLES L (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:SLAUGHTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7296
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39282-7296
Mailing Address - Country:US
Mailing Address - Phone:601-372-9229
Mailing Address - Fax:601-372-9990
Practice Address - Street 1:820 COOPER RD
Practice Address - Street 2:SUITE J
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-4099
Practice Address - Country:US
Practice Address - Phone:601-372-9229
Practice Address - Fax:601-372-9990
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00489050Medicaid
MS00489050Medicaid