Healthcare Provider Details

I. General information

NPI: 1760973325
Provider Name (Legal Business Name): MILDRED WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2018
Last Update Date: 05/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9343 S SANGAMON ST
CHICAGO IL
60620-2734
US

IV. Provider business mailing address

9343 S SANGAMON ST
CHICAGO IL
60620-2734
US

V. Phone/Fax

Practice location:
  • Phone: 773-699-4281
  • Fax: 773-496-0909
Mailing address:
  • Phone: 773-699-4281
  • Fax: 773-496-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberW300-6008-4709
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: