Healthcare Provider Details

I. General information

NPI: 1255823993
Provider Name (Legal Business Name): RYAN HERRING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

2139 ELEMENTS WAY
IRVINE CA
92612-1533
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7890
  • Fax:
Mailing address:
  • Phone: 309-251-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA164405
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberA164405
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberA164405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: