Healthcare Provider Details

I. General information

NPI: 1972906873
Provider Name (Legal Business Name): VANTAGE CANCER CARE NETWORK OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ROSECRANS AVE SUITE 400
MANHATTAN BEACH CA
90266-3763
US

IV. Provider business mailing address

1500 ROSECRANS AVE SUITE 400
MANHATTAN BEACH CA
90266-3763
US

V. Phone/Fax

Practice location:
  • Phone: 310-335-4000
  • Fax:
Mailing address:
  • Phone: 310-335-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN UDICIOUS
Title or Position: VICE PRESIDENT, GENERAL COUNSEL
Credential: ESQUIRE
Phone: 610-519-0550