Provider Demographics
NPI:1952453672
Name:HERRERA, JOSE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:
Last Name:HERRERA
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 1:1095 NORTH D STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410
Mailing Address - Country:US
Mailing Address - Phone:909-888-7649
Mailing Address - Fax:909-888-1955
Practice Address - Street 1:1095 NORTH D STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410
Practice Address - Country:US
Practice Address - Phone:909-888-7649
Practice Address - Fax:909-888-1955
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27442111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0274420Medicaid
U94826Medicare UPIN
CADC0274420Medicaid