Organization
PROVIDENCE PODIATRY CARE, INC.
Active
Other names
Providence Podiaty Care, Inc
Organization subpart
No
Provider details
NPI number
Authorized official
EDDIE AVILA (OWNER/ADMINISTRATOR)
(909) 944-0486
Entity
Organization
Contact information
Practice address
10621 CHURCH ST STE 120, RANCHO CUCAMONGA, CA 91730-6834
(909) 944-0481
(909) 944-3161
Mailing address
10621 CHURCH ST STE 120, RANCHO CUCAMONGA, CA 91730-6834
(909) 944-0481
(909) 944-3161
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1831127349
MOLINA MEDICAL GROUP
CA
05
—
1831127349
—
CA
Enumeration date
09/30/2021
Last updated
10/04/2021
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