Provider Demographics
NPI:1962690719
Name:WHITE, KIRK CLOYDE (LAC)
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:CLOYDE
Last Name:WHITE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 CHRISTIAN HL
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-9793
Mailing Address - Country:US
Mailing Address - Phone:802-476-8028
Mailing Address - Fax:802-234-9670
Practice Address - Street 1:64 WARREN ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-2946
Practice Address - Country:US
Practice Address - Phone:802-476-8028
Practice Address - Fax:802-234-9670
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091-0000080171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist