Provider Demographics
NPI:1578995239
Name:HEREDIA, CORAL (BA)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRIG WAY
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-9431
Mailing Address - Country:US
Mailing Address - Phone:209-829-0827
Mailing Address - Fax:
Practice Address - Street 1:815 W 18TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-4604
Practice Address - Country:US
Practice Address - Phone:209-725-2125
Practice Address - Fax:209-726-4430
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator