Healthcare Provider Details

I. General information

NPI: 1780130872
Provider Name (Legal Business Name): MR. WILLIAM HUGH WHITE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18559 WALNUT AVE
COUNTRY CLUB HILLS IL
60478-5558
US

IV. Provider business mailing address

18559 WALNUT AVE
COUNTRY CLUB HILLS IL
60478-5558
US

V. Phone/Fax

Practice location:
  • Phone: 708-252-6426
  • Fax: 708-851-1522
Mailing address:
  • Phone: 708-252-6426
  • Fax: 708-851-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: