Provider Demographics
NPI:1053111054
Name:ALLEN, SLADE
Entity type:Individual
Prefix:
First Name:SLADE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 HIDDEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WOODWORTH
Mailing Address - State:LA
Mailing Address - Zip Code:71485-9529
Mailing Address - Country:US
Mailing Address - Phone:318-290-0913
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:800-375-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA336500246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory