Provider Demographics
NPI:1548979552
Name:WHITE, DWAYNE RAYNARD
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:RAYNARD
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 1:786 BROOKHURST BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8984
Mailing Address - Country:US
Mailing Address - Phone:209-983-8633
Mailing Address - Fax:
Practice Address - Street 1:786 BROOKHURST BLVD
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8984
Practice Address - Country:US
Practice Address - Phone:209-983-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator