Healthcare Provider Details

I. General information

NPI: 1891782769
Provider Name (Legal Business Name): WAYNE WALTER WHITE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE 12TH ST
FT LAUDERDALE FL
33316-1816
US

IV. Provider business mailing address

200 SE 12TH ST
FT LAUDERDALE FL
33316-1816
US

V. Phone/Fax

Practice location:
  • Phone: 954-463-2404
  • Fax: 954-463-2307
Mailing address:
  • Phone: 954-463-2404
  • Fax: 954-463-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH0006397
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: