Provider Demographics
NPI:1366659344
Name:WHITESIDE, HARRY (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:HARRY
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 MEADOWLAND DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706
Mailing Address - Country:US
Mailing Address - Phone:409-860-4067
Mailing Address - Fax:
Practice Address - Street 1:8750 PHELAN BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5133
Practice Address - Country:US
Practice Address - Phone:409-981-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX465174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist