Provider Demographics
NPI:1023623691
Name:WHITE, LEE
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:
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 1:250 GREENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-9185
Mailing Address - Country:US
Mailing Address - Phone:440-361-4493
Mailing Address - Fax:440-361-4493
Practice Address - Street 1:250 GREENRIDGE DR
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-9185
Practice Address - Country:US
Practice Address - Phone:440-361-4493
Practice Address - Fax:440-361-4493
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0402418253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402418Medicaid