Provider Demographics
NPI:1891741211
Name:WHITE, LISA K (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:K
Last Name:WHITE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:K
Other - Last Name:WEBBER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2370 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4456
Mailing Address - Country:US
Mailing Address - Phone:770-939-5525
Mailing Address - Fax:
Practice Address - Street 1:2370 MAIN ST
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4456
Practice Address - Country:US
Practice Address - Phone:770-939-5525
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCBSWMedicare UPIN