Healthcare Provider Details

I. General information

NPI: 1053616706
Provider Name (Legal Business Name): PROVIDENCE MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19333 BEAR VALLEY RD SUITE 106
APPLE VALLEY CA
92308-5148
US

IV. Provider business mailing address

PO BOX 31001 - 1920
PASADENA CA
91110-1920
US

V. Phone/Fax

Practice location:
  • Phone: 760-240-5505
  • Fax: 760-245-5525
Mailing address:
  • Phone: 714-449-4800
  • Fax: 714-449-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD W. ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786