=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245050897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MIKE HERRERA III
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2024
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57131 LAKEVIEW RD
-----------------------------------------------------
City | BAKER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-389-8582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1366 WHITEWOOD DR
-----------------------------------------------------
City | MENTONE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92359-1623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-389-8582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 360159AP
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------