NPIMap

Organization Active NPI

Providence Podiatry Care, Inc

  • Foot & Ankle Surgery Podiatrist
  • San Bernardino, CA
National Provider Identifier
1376202986
Registry record updated Jun 21, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X
Legal business name
PROVIDENCE PODIATRY CARE, INC
Practice address
473 E Carnegie Drive
Suite 200
San Bernardino, CA 92408
Phone
(909) 244-7430
Fax
(909) 495-1380
NPI assigned
Dec 10, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 21, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Eddie Avila
Title
Secretary/Treasuer
Phone
(909) 244-7430

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Foot & Ankle Surgery PodiatristGroup: 193400000X SINGLE SPECIALTY GROUP 213ES0103X Primary

Addresses

Primary practice location

473 E Carnegie Drive
Suite 200
San Bernardino, CA 92408

Mailing address

473 E Carnegie Drive
Suite 200
San Bernardino, CA 92408
Phone (909) 244-7430

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address eddieavila@icloud.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211217002222 CA Part B Supplier - Clinic/Group Practice 6507256708 Receives reassigned benefits from 14 practitioners
Practice locations: Rancho Cucamonga, CA; San Bernardino, CA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1639094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1687305600000",
    "number": "1376202986",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "473 E CARNEGIE DRIVE",
            "address_2": "SUITE 200",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "92408",
            "telephone_number": "909-244-7430",
            "fax_number": "909-495-1380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "473 E CARNEGIE DRIVE",
            "address_2": "SUITE 200",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "92408",
            "telephone_number": "909-244-7430",
            "fax_number": "909-495-1380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE PODIATRY CARE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-12-10",
        "last_updated": "2023-06-21",
        "certification_date": "2023-06-07",
        "status": "A",
        "authorized_official_last_name": "AVILA",
        "authorized_official_first_name": "EDDIE",
        "authorized_official_title_or_position": "SECRETARY/TREASUER",
        "authorized_official_telephone_number": "909-244-7430"
    },
    "taxonomies": [
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "eddieavila@icloud.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "10621 Church St Ste 120",
            "city": "Rancho Cucamonga",
            "state": "CA",
            "country_code": "US",
            "postal_code": "917306834",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in San Bernardino, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.