Provider Demographics
NPI:1982362596
Name:SLATER, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SLATER
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 1:8512 KILLY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48166-9492
Mailing Address - Country:US
Mailing Address - Phone:734-512-3679
Mailing Address - Fax:
Practice Address - Street 1:8512 KILLY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:MI
Practice Address - Zip Code:48166-9492
Practice Address - Country:US
Practice Address - Phone:734-512-3679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI506153146N00000X
MI4401006508227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic