Healthcare Provider Details

I. General information

NPI: 1205162740
Provider Name (Legal Business Name): EDITH VIRGINIA WHITING M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2009
Last Update Date: 10/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SARACENO
NEWPORT COAST CA
92657-1305
US

IV. Provider business mailing address

23 SARACENO
NEWPORT COAST CA
92657-1305
US

V. Phone/Fax

Practice location:
  • Phone: 949-689-3941
  • Fax:
Mailing address:
  • Phone: 949-689-3941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License NumberMTA 22170
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License NumberTN38921
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number4353
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: