Healthcare Provider Details

I. General information

NPI: 1316638653
Provider Name (Legal Business Name): ENDEAVOR MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7665 CREOLE PL UNIT 3
RANCHO CUCAMONGA CA
91739-7503
US

IV. Provider business mailing address

10722 ARROW RTE STE 304
RANCHO CUCAMONGA CA
91730-4811
US

V. Phone/Fax

Practice location:
  • Phone: 909-484-2865
  • Fax: 909-941-6974
Mailing address:
  • Phone: 909-262-6125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LOURDES TRIGUEROS
Title or Position: CREDENTIALING
Credential: CREDENTIALING
Phone: 909-262-6125