Provider Demographics
NPI:1093317927
Name:WHITE, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21300 LORAIN RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21300 LORAIN RD STE 4
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2160
Practice Address - Country:US
Practice Address - Phone:216-556-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker