Provider Demographics
NPI:1245050897
Name:HERRERA, MIKE III
Entity type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:HERRERA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 WHITEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-1623
Mailing Address - Country:US
Mailing Address - Phone:909-389-8582
Mailing Address - Fax:
Practice Address - Street 1:57131 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:CA
Practice Address - Zip Code:92309
Practice Address - Country:US
Practice Address - Phone:909-389-8582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360159AP405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional