Healthcare Provider Details

I. General information

NPI: 1306358064
Provider Name (Legal Business Name): IVAN HERRERA HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-280-5923
  • Fax:
Mailing address:
  • Phone: 209-280-5923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95375269
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number40627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: