Provider Demographics
NPI:1689698581
Name:WHITE, MARK R (MS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:WHITE
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 STONEHENGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8336
Mailing Address - Country:US
Mailing Address - Phone:336-674-4300
Mailing Address - Fax:336-674-4290
Practice Address - Street 1:4530 SE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-9784
Practice Address - Country:US
Practice Address - Phone:336-674-4300
Practice Address - Fax:336-674-4290
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer