Healthcare Provider Details

I. General information

NPI: 1902804024
Provider Name (Legal Business Name): SUSAN DRAPER WHITE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6803 C ST
SPRINGFIELD OR
97478-7389
US

IV. Provider business mailing address

6803 C ST
SPRINGFIELD OR
97478-7389
US

V. Phone/Fax

Practice location:
  • Phone: 541-579-0314
  • Fax:
Mailing address:
  • Phone: 541-579-0314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number5776
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number5721
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3958
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2301009286
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: