Provider Demographics
NPI:1053788547
Name:WHITE, KEVIN C (BA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:WHITE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14515 HAMLIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1608
Mailing Address - Country:US
Mailing Address - Phone:818-989-7475
Mailing Address - Fax:818-908-2434
Practice Address - Street 1:14515 HAMLIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1608
Practice Address - Country:US
Practice Address - Phone:818-989-7475
Practice Address - Fax:818-908-2434
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner