Basic Information
| Provider Information | |||||||||
| NPI: | 1134750474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRICK | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 S DIAMOND BAR BLVD # 428 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917651607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099928610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263317331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95013738 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.