Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 27-1620 | OR |
NPI | 1407853914 |
---|---|
Provider Name | Dr. Frank Thomas Heresco |
First Address | Corvallis, OR 97330-6308 |
Second Address | Corvallis, OR 97330-6308 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2005 |
Last Update Date | 11/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008172 | (05) | OR |
T60468 | (02) |