Healthcare Provider Details

I. General information

NPI: 1255594925
Provider Name (Legal Business Name): VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E VALENCIA MESA DR
FULLERTON CA
92835-3809
US

IV. Provider business mailing address

PO BOX 10050
MANHATTAN BEACH CA
90267-7550
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5632
  • Fax: 714-992-3081
Mailing address:
  • Phone: 310-335-4056
  • Fax: 310-335-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: LESLIE E BOTNICK
Title or Position: CEO
Credential: MD
Phone: 310-335-4065