Healthcare Provider Details

I. General information

NPI: 1336302983
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

1100 W STEWART DR
ORANGE CA
92868-3849
US

IV. Provider business mailing address

PO BOX 10050
MANHATTAN BEACH CA
90267-7550
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-8153
  • Fax: 714-744-8573
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