Healthcare Provider Details

I. General information

NPI: 1003491812
Provider Name (Legal Business Name): BRENTON JOSEPH WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 6TH AVE W
HUNTINGTON WV
25701-0028
US

IV. Provider business mailing address

836 COUNTY ROAD 119
IRONTON OH
45638-8114
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-8014
  • Fax:
Mailing address:
  • Phone: 740-302-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: