Healthcare Provider Details

I. General information

NPI: 1558029041
Provider Name (Legal Business Name): INNOVATIVE CANCER INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 W 21ST ST
HIALEAH FL
33010-2614
US

IV. Provider business mailing address

5995 SW 71ST ST STE 1-B
SOUTH MIAMI FL
33143-3531
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-6833
  • Fax: 305-666-4030
Mailing address:
  • Phone: 305-669-6833
  • Fax:

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: MRS. MICHELLE MILAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 305-669-6833