Provider Demographics
NPI:1679205371
Name:WHITE, CARLOS VAUGHN
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:VAUGHN
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 1:11318 NOTRE DAME AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-2552
Mailing Address - Country:US
Mailing Address - Phone:216-502-6097
Mailing Address - Fax:
Practice Address - Street 1:11318 NOTRE DAME AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2552
Practice Address - Country:US
Practice Address - Phone:216-502-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator