Basic Information
| Provider Information | |||||||||
| NPI: | 1689619124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | CARYN | ||||||||
| MiddleName: | KENDRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 S 5600 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841204639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016764405 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4535 S 5600 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841204639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016764405 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5597655-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1164672770 | 05 | UT | MEDICAID |