Healthcare Provider Details

I. General information

NPI: 1700195500
Provider Name (Legal Business Name): MR. BRYAN G HERFURTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 MARCONI AVE
SACRAMENTO CA
95821-5303
US

IV. Provider business mailing address

6692 MERCHANDISE WAY STE B
DIAMOND SPRINGS CA
95619-9453
US

V. Phone/Fax

Practice location:
  • Phone: 916-485-6500
  • Fax:
Mailing address:
  • Phone: 530-626-2589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: