Healthcare Provider Details

I. General information

NPI: 1255707246
Provider Name (Legal Business Name): HERACLIO VIDAL HERRERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26889 CHERRY WILLOW DR
SANTA CLARITA CA
91387-1813
US

IV. Provider business mailing address

26889 CHERRY WILLOW DR
SANTA CLARITA CA
91387-1813
US

V. Phone/Fax

Practice location:
  • Phone: 818-288-8112
  • Fax:
Mailing address:
  • Phone: 818-288-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number837669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: