Healthcare Provider Details

I. General information

NPI: 1902893902
Provider Name (Legal Business Name): NORTH FLORIDA CANCER CENTER LAKE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 SW HIGHWAY 47
LAKE CITY FL
32025
US

IV. Provider business mailing address

795 SW STATE ROAD 47
LAKE CITY FL
32025-0453
US

V. Phone/Fax

Practice location:
  • Phone: 386-758-7822
  • Fax: 386-758-2224
Mailing address:
  • Phone: 386-758-7822
  • Fax: 386-758-2224

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: JOAN R GLADNEY
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 352-474-6190