Healthcare Provider Details

I. General information

NPI: 1235186859
Provider Name (Legal Business Name): PREMIERE ONCOLOGY, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SANTA MONICA BLVD STE 600
SANTA MONICA CA
90404-2131
US

IV. Provider business mailing address

2020 SANTA MONICA BLVD STE 600
SANTA MONICA CA
90404-2131
US

V. Phone/Fax

Practice location:
  • Phone: 310-633-8400
  • Fax: 310-633-8419
Mailing address:
  • Phone: 310-633-8400
  • Fax: 310-633-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA49741
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA52720
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG73680
License Number StateCA

VIII. Authorized Official

Name: DR. LEE S ROSEN
Title or Position: PREISDENT AND CEO
Credential: M.D.
Phone: 310-633-8400