=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578377636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHANIEL TRISTAN HERRERA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11550 LEGACY DR STE 480
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-8678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-377-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1904 BUFFALO AVE
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78589-3458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-961-7510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 16351
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 16351
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------