Healthcare Provider Details

I. General information

NPI: 1003871666
Provider Name (Legal Business Name): JERRY EDWARD CAVENDER II ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W FRANCIS ST
ONTARIO CA
91762-6214
US

IV. Provider business mailing address

PO BOX 2257
GLENDORA CA
91740-2257
US

V. Phone/Fax

Practice location:
  • Phone: 909-988-7411
  • Fax: 909-467-5238
Mailing address:
  • Phone: 626-825-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: