Healthcare Provider Details

I. General information

NPI: 1104005594
Provider Name (Legal Business Name): WHITE'S PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 CHATTANOOGA AVE SUITE 1
DALTON GA
30720-2671
US

IV. Provider business mailing address

1575 CHATTANOOGA AVE SUITE 1
DALTON GA
30720-2671
US

V. Phone/Fax

Practice location:
  • Phone: 706-876-2131
  • Fax:
Mailing address:
  • Phone: 706-876-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number022667
License Number StateGA

VIII. Authorized Official

Name: MENDY HARBOUR
Title or Position: BILLING MANAGER
Credential:
Phone: 706-876-2179