Provider Demographics
NPI:1265002463
Name:WHITE, KAYLON M
Entity type:Individual
Prefix:
First Name:KAYLON
Middle Name:M
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 1:1753 BUCCOLA AVE
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3323
Mailing Address - Country:US
Mailing Address - Phone:504-335-8795
Mailing Address - Fax:
Practice Address - Street 1:3760 SOUTHDOWN MANDALAY RD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-8031
Practice Address - Country:US
Practice Address - Phone:504-454-8697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver