Provider Demographics
NPI:1053462036
Name:HERNDON, RON (DC)
Entity Type:Individual
Prefix:DR
First Name:RON
Middle Name:
Last Name:HERNDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2087 CLIFF GOOKIN BLVD.
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:662-842-8413
Mailing Address - Fax:662-844-3292
Practice Address - Street 1:2087 CLIFF GOOKIN BLVD.
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-842-8413
Practice Address - Fax:662-844-3292
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS399111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST21216Medicare UPIN