Healthcare Provider Details

I. General information

NPI: 1487885372
Provider Name (Legal Business Name): FOOTHILLS PAIN MANAGEMENT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 W COLLEGE ST
COVINA CA
91723-1902
US

IV. Provider business mailing address

PO BOX 209
COVINA CA
91723-0209
US

V. Phone/Fax

Practice location:
  • Phone: 626-608-7320
  • Fax: 626-608-7322
Mailing address:
  • Phone: 626-608-7320
  • Fax: 626-608-7322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberC52522
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. HETAL MEHTA
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-608-7320