1730443342 NPI number — MR. TERRY DEWAYNE WHITE JR. MS, ATC

Table of content: MR. TERRY DEWAYNE WHITE JR. MS, ATC (NPI 1730443342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730443342 NPI number — MR. TERRY DEWAYNE WHITE JR. MS, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
TERRY
Provider Middle Name:
DEWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MS, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITE
Provider Other First Name:
TJ
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, ATC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1730443342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 DISCOVERY BAY LN
Provider Second Line Business Mailing Address:
#22
Provider Business Mailing Address City Name:
HOT SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71913-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-860-8700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 PROSPECT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71901-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-622-3335
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AT 501 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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