Provider Demographics
NPI:1154352037
Name:SAN BERNARDINO FOOT CLINIC, INC.
Entity type:Organization
Organization Name:SAN BERNARDINO FOOT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUEVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-882-3800
Mailing Address - Street 1:2095 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4834
Mailing Address - Country:US
Mailing Address - Phone:909-882-3800
Mailing Address - Fax:909-882-3380
Practice Address - Street 1:2095 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4834
Practice Address - Country:US
Practice Address - Phone:909-882-3800
Practice Address - Fax:909-882-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4416213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E44161Medicaid
CACI863BOtherMEDICARE PTAN
CADD297ZOtherMEDICARE INDIVIDUAL
CA0253335Medicaid
CADD297ZOtherMEDICARE INDIVIDUAL
CACI863BOtherMEDICARE PTAN
CA000E44161Medicaid
CA0253335Medicaid