Healthcare Provider Details

I. General information

NPI: 1578604039
Provider Name (Legal Business Name): JOSE DELFIN HERRERA JR. PCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 N CALIFORNIA STREET
SOCORRO NM
87801
US

IV. Provider business mailing address

701 COULSON DR
SOCORRO NM
87801-4767
US

V. Phone/Fax

Practice location:
  • Phone: 505-838-0800
  • Fax: 505-838-3999
Mailing address:
  • Phone: 505-838-0800
  • Fax: 505-838-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1572
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: