Healthcare Provider Details

I. General information

NPI: 1417525056
Provider Name (Legal Business Name): ANGEL HEREDIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E SANTA CLARA ST
SAN JOSE CA
95113-1936
US

IV. Provider business mailing address

425 E SANTA CLARA ST
SAN JOSE CA
95113-1936
US

V. Phone/Fax

Practice location:
  • Phone: 408-800-4095
  • Fax:
Mailing address:
  • Phone: 669-245-3429
  • Fax: 408-800-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: