Basic Information
| Provider Information | |||||||||
| NPI: | 1760645329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10050 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902677550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354056 | ||||||||
| FaxNumber: | 3103354098 | ||||||||
| Practice Location | |||||||||
| Address1: | 23023 SHERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | WEST HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913072000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188841683 | ||||||||
| FaxNumber: | 8188843861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOTNICK | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3103354065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.