Healthcare Provider Details

I. General information

NPI: 1437287117
Provider Name (Legal Business Name): JOHN WAYNE CANCER INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

IV. Provider business mailing address

2200 SANTA MONICA BLVD
SANTA MONICA CA
90404-2312
US

V. Phone/Fax

Practice location:
  • Phone: 310-449-5253
  • Fax:
Mailing address:
  • Phone: 310-449-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number332B00000X
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: STUART P JACKSON
Title or Position: DIRECTOR, FINANCIAL SERVICES
Credential:
Phone: 310-449-5253