Provider Demographics
NPI:1750869889
Name:WHITEAR, KANSAS
Entity type:Individual
Prefix:
First Name:KANSAS
Middle Name:
Last Name:WHITEAR
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 1:7295 S 2050 E
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-7737
Mailing Address - Country:US
Mailing Address - Phone:801-979-4638
Mailing Address - Fax:801-605-8549
Practice Address - Street 1:7295 S 2050 E
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405-7737
Practice Address - Country:US
Practice Address - Phone:801-979-4638
Practice Address - Fax:801-605-8549
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9578235-1714332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
620254000OtherDEPARTMENT OF LABOR