Provider Demographics
NPI:1497715106
Name:WHITE, KENNETH STEPHEN (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:STEPHEN
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 1:3410 FAR WEST BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3194
Mailing Address - Country:US
Mailing Address - Phone:512-346-5735
Mailing Address - Fax:512-233-2792
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3194
Practice Address - Country:US
Practice Address - Phone:512-346-5735
Practice Address - Fax:512-233-2792
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2229111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB06002321Medicaid
TXBC/BS OF TEXASOtherBC/BS ID
TXDC2229OtherLICENSE ID
TXDC2229OtherLICENSE ID
TXB06002321Medicaid