Provider Demographics
NPI:1578627154
Name:WHITE, LARRY EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EDWARD
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 1:787 PEARL ST.
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-583-5660
Mailing Address - Fax:508-583-1800
Practice Address - Street 1:787 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4425
Practice Address - Country:US
Practice Address - Phone:508-583-5660
Practice Address - Fax:508-583-1800
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39454OtherBLUE CROSS GROUP
MAWHY35353OtherBLUE CROSS
MA1602985Medicaid
MAY35353Medicare Oscar/Certification
MAWHY35353OtherBLUE CROSS