Provider Demographics
NPI:1669691523
Name:WHITE, JUSTIN PATRICK (ATC, CSCS, NSCA-CPT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:PATRICK
Last Name:WHITE
Suffix:
Gender:M
Credentials:ATC, CSCS, NSCA-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 YORK WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4110
Mailing Address - Country:US
Mailing Address - Phone:386-299-5387
Mailing Address - Fax:
Practice Address - Street 1:600 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3966
Practice Address - Country:US
Practice Address - Phone:386-226-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 10742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer