Provider Demographics
NPI:1124796461
Name:WHITE, MARK JAMES
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAMES
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 1:2026 LAPEER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4156
Mailing Address - Country:US
Mailing Address - Phone:810-969-7899
Mailing Address - Fax:
Practice Address - Street 1:2026 LAPEER AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4156
Practice Address - Country:US
Practice Address - Phone:810-969-7899
Practice Address - Fax:810-432-8081
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5803001724343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)