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General NPI Number Information
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NPI Number | 1639948672
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Entity Type | Individual
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Provider Name | ENRIQUE V HERRERA ESTRADA SURGICAL ASSISTANT
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Gender | Male
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Dates
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Enumeration Date | 01/01/2024
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Last Update Date | 01/01/2024
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Provider Practice Location Address
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Address Line | 6201 W 95TH ST
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City | OAK LAWN
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State | IL
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Zip | 60453-3888
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Country | US
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Telephone | 708-636-9393
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Fax |
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Provider Business Mailing Address
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Address Line | 2211 S HIGHLAND AVE APT 4C
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City | LOMBARD
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State | IL
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Zip | 60148-5349
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Country | US
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Telephone | 708-513-1584
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 23-766
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License Number State | WI
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