Provider Demographics
NPI:1033881735
Name:PROVIDENCE PODIATRY CARE, INC.
Entity Type:Organization
Organization Name:PROVIDENCE PODIATRY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-944-0486
Mailing Address - Street 1:10621 CHURCH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6834
Mailing Address - Country:US
Mailing Address - Phone:909-944-0481
Mailing Address - Fax:909-944-3161
Practice Address - Street 1:10621 CHURCH ST STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6834
Practice Address - Country:US
Practice Address - Phone:909-944-0481
Practice Address - Fax:909-944-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831127349Medicaid
CA1831127349OtherMOLINA MEDICAL GROUP