Provider Demographics
NPI:1316122997
Name:WHITE, ANDREA MARIE (DC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1193
Mailing Address - Country:US
Mailing Address - Phone:314-960-8876
Mailing Address - Fax:
Practice Address - Street 1:2 CLUB CENTRE CT STE 3
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3503
Practice Address - Country:US
Practice Address - Phone:314-960-8876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00578Medicare UPIN