Provider Demographics
NPI:1730453176
Name:KENT D VANDERSLICE DC PC
Entity type:Organization
Organization Name:KENT D VANDERSLICE DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANDERSLICE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-713-8883
Mailing Address - Street 1:185 REGINA CIR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 S MARIETTA PKWY SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2811
Practice Address - Country:US
Practice Address - Phone:770-422-1059
Practice Address - Fax:770-422-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCFXPMedicare PIN