Basic Information
| Provider Information | |||||||||
| NPI: | 1922482694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTER PARK CANCER CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2865 E COAST HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CORONA DEL MAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926252236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492073300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1561 W FAIRBANKS AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074784920 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCKNIGHT | ||||||||
| AuthorizedOfficialFirstName: | NICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPLIANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9493855015 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CHC | ||||||||
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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.