Healthcare Provider Details

I. General information

NPI: 1316262421
Provider Name (Legal Business Name): CANDACE MARIE HERZOG MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4516 109TH ST
LUBBOCK TX
79424-5792
US

IV. Provider business mailing address

4516 109TH ST
LUBBOCK TX
79424-5792
US

V. Phone/Fax

Practice location:
  • Phone: 832-465-5908
  • Fax:
Mailing address:
  • Phone: 832-465-5908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07300
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT07300
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: