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General NPI Number Information
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NPI Number | 1851623185
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Entity Type | Organization
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Legal Business Name | TW WHITE OD PC
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Dates
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Enumeration Date | 02/11/2010
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Last Update Date | 02/11/2010
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Provider Practice Location Address
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Address Line | 410 W HAYWARD DR
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City | MOUNT VERNON
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State | MO
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Zip | 65712-7368
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Country | US
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Telephone | 417-466-2100
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Fax | 417-466-0432
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Provider Business Mailing Address
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Address Line | PO BOX 311 410 W HAYWARD DR
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City | MOUNT VERNON
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State | MO
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Zip | 65712-0311
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Country | US
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Telephone | 417-466-2100
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Fax | 417-466-0432
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Authorized Official
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Title or Position | OPTOMETRIC DOCTOR
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Name | DR. T W WHITE
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Credential | O.D.
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Telephone | 417-466-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2104
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License Number State | MO
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