Basic Information
| Provider Information | |||||||||
| NPI: | 1457753592 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANTAGE CANCER CARE NETWORK OF ARIZONA, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROSECRANS AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902663707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 GAIL GARDNER WAY | ||||||||
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| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863051690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287761040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2014 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOTNICK | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3235955769 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.