Healthcare Provider Details

I. General information

NPI: 1780650424
Provider Name (Legal Business Name): SCOTT ALAN WHITE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 W MONTROSE AVE
NORRIDGE IL
60706-1153
US

IV. Provider business mailing address

1639 N NARRAGANSETT AVE
CHICAGO IL
60639-3823
US

V. Phone/Fax

Practice location:
  • Phone: 708-456-4242
  • Fax: 708-456-1573
Mailing address:
  • Phone: 708-516-3761
  • Fax: 708-456-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-0000137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: