Provider Demographics
NPI:1376202986
Name:PROVIDENCE PODIATRY CARE, INC
Entity Type:Organization
Organization Name:PROVIDENCE PODIATRY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASUER
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:909-244-7430
Mailing Address - Street 1:473 E CARNEGIE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:909-244-7430
Mailing Address - Fax:909-495-1380
Practice Address - Street 1:473 E CARNEGIE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-244-7430
Practice Address - Fax:909-495-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty