Provider Demographics
NPI:1821468935
Name:WHITE, CLARKE (HIS)
Entity Type:Individual
Prefix:
First Name:CLARKE
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310901
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-0901
Mailing Address - Country:US
Mailing Address - Phone:334-393-6688
Mailing Address - Fax:
Practice Address - Street 1:4440 W MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1178
Practice Address - Country:US
Practice Address - Phone:334-794-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2257237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist