Basic Information
| Provider Information | |||||||||
| NPI: | 1558966671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | PEARL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443193028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2020 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 0002013 | OH | Y |
No ID Information.