Healthcare Provider Details

I. General information

NPI: 1629181748
Provider Name (Legal Business Name): STEPHEN C. WHITE PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MEDICAL ARTS AVE NE
ALBUQUERQUE NM
87102-2708
US

IV. Provider business mailing address

1025 MEDICAL ARTS AVE NE
ALBUQUERQUE NM
87102-2708
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-9020
  • Fax: 505-232-9606
Mailing address:
  • Phone: 505-272-9020
  • Fax: 505-232-9606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7649
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4366
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: