Healthcare Provider Details

I. General information

NPI: 1740380245
Provider Name (Legal Business Name): COREY MICHAEL WHITE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD SUITE 110
BATON ROUGE LA
70810-7827
US

IV. Provider business mailing address

14339 MEADOW RIDGE DR
BATON ROUGE LA
70817-5254
US

V. Phone/Fax

Practice location:
  • Phone: 225-408-7990
  • Fax:
Mailing address:
  • Phone: 225-753-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number06495
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: