Provider Demographics
NPI:1700121290
Name:WHITE, CHARLES LESLIE
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LESLIE
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 1:2161 NW 11TH DR
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1924
Mailing Address - Country:US
Mailing Address - Phone:352-493-7830
Mailing Address - Fax:352-493-4840
Practice Address - Street 1:2161 NW 11TH DR
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1924
Practice Address - Country:US
Practice Address - Phone:352-493-7830
Practice Address - Fax:352-493-4840
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4659237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist