Basic Information
| Provider Information | |||||||||
| NPI: | 1770581183 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH COUNTY RADIATION ONCOLOGY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFIC RADIATION ONCOLOGY MEDICAL GROUP OF SAN DIEGO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 477 N EL CAMINO REAL | ||||||||
| Address2: | STE D100 | ||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920241328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606344300 | ||||||||
| FaxNumber: | 7606329791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2005 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOURBEAU | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7605999545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0062074 | 05 | CA | MEDICAID |