Basic Information
| Provider Information | |||||||||
| NPI: | 1265509657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONCOLOGY THERAPIES OF VISTA MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920817815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605999545 | ||||||||
| FaxNumber: | 7605999549 | ||||||||
| Practice Location | |||||||||
| Address1: | 916 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920817815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605999545 | ||||||||
| FaxNumber: | 7605999549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOURBEAU | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7605999545 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | 00A42436A0 | 05 | CA | MEDICAID | 00A537410 | 05 | CA | MEDICAID | 00A830540 | 05 | CA | MEDICAID | 00G676470 | 05 | CA | MEDICAID |