Provider Demographics
NPI:1114649506
Name:WHITE, ROBERT RUSSELL
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RUSSELL
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 1:250 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2641
Mailing Address - Country:US
Mailing Address - Phone:304-256-0444
Mailing Address - Fax:
Practice Address - Street 1:18566 WEBSTER ROAD
Practice Address - Street 2:
Practice Address - City:CRAIGSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26205
Practice Address - Country:US
Practice Address - Phone:304-256-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant