Healthcare Provider Details

I. General information

NPI: 1346561289
Provider Name (Legal Business Name): 21ST CENTURY ONCOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E REDSTONE AVE SUITE 102
CRESTVIEW FL
32539-5326
US

IV. Provider business mailing address

2234 COLONIAL BLVD
FORT MYERS FL
33907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-6333
  • Fax: 850-682-0865
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANNA HARRISON
Title or Position: SR. DIRECTOR OF PROVIDER RELATIONS
Credential:
Phone: 239-931-7342