Healthcare Provider Details

I. General information

NPI: 1750400719
Provider Name (Legal Business Name): RODERICK LEWIS WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E 7TH ST
LONG BEACH CA
90804-4590
US

IV. Provider business mailing address

1359 W 69TH ST
LOS ANGELES CA
90044-2534
US

V. Phone/Fax

Practice location:
  • Phone: 562-284-0108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: