Healthcare Provider Details

I. General information

NPI: 1265170765
Provider Name (Legal Business Name): AVIDA HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N MOUNTAIN AVE STE 205
UPLAND CA
91786-5714
US

IV. Provider business mailing address

222 N MOUNTAIN AVE STE 205
UPLAND CA
91786-5714
US

V. Phone/Fax

Practice location:
  • Phone: 909-333-7133
  • Fax: 909-236-7989
Mailing address:
  • Phone: 909-333-7133
  • Fax: 909-236-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JURO CHRIST ENRIQUEZ ADEFUIN
Title or Position: CEO
Credential:
Phone: 562-552-7775