MEDICARE: DONALD WHITE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1053603639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD WHITE JR.

Provider Business Mailing Address
First Line	:	1321 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9066
Country	:	US
Telephone Number	:	702-826-3219
Fax Number	:

Provider Business Practice Location Address
First Line	:	1321 S RAINBOW BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9066
Country	:	US
Telephone Number	:	702-826-3219
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	01/21/2014

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