Provider Demographics
NPI:1205840832
Name:WHITE, SCOTT C (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:WHITE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0743
Mailing Address - Country:US
Mailing Address - Phone:208-359-8265
Mailing Address - Fax:208-656-3206
Practice Address - Street 1:1096 ERIKSON DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5297
Practice Address - Country:US
Practice Address - Phone:208-656-3205
Practice Address - Fax:208-656-3206
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149474OtherBLUE SHIELD
C4439OtherBLUE CROSS
IDM8070907Medicaid
U04057Medicare UPIN
IDM8070907Medicaid