Basic Information
| Provider Information | |||||||||
| NPI: | 1275822918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | ADELAIDE | ||||||||
| MiddleName: | ROBINSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBINSON | ||||||||
| OtherFirstName: | ADELAIDE | ||||||||
| OtherMiddleName: | HILL | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4745 S 3200 W | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018583461 | ||||||||
| FaxNumber: | 8019552389 | ||||||||
| Practice Location | |||||||||
| Address1: | 1388 S NAVAJO ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841043493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019552360 | ||||||||
| FaxNumber: | 8019829232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2011 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51664 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9429781-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.