Provider Demographics
NPI:1891782769
Name:WHITE, WAYNE WALTER (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WALTER
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 1:200 SE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1816
Mailing Address - Country:US
Mailing Address - Phone:954-463-2404
Mailing Address - Fax:954-463-2307
Practice Address - Street 1:200 SE 12TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1816
Practice Address - Country:US
Practice Address - Phone:954-463-2404
Practice Address - Fax:954-463-2307
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380318000Medicaid
FLU22779Medicare UPIN
FL380318000Medicaid