Healthcare Provider Details

I. General information

NPI: 1730176215
Provider Name (Legal Business Name): NORTH FLORIDA CANCER CENTER LIVE OAK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 OHIO AVE N
LIVE OAK FL
32064-4820
US

IV. Provider business mailing address

1500 OHIO AVE N
LIVE OAK FL
32064-4820
US

V. Phone/Fax

Practice location:
  • Phone: 386-362-1174
  • Fax: 386-362-1142
Mailing address:
  • Phone: 386-362-1174
  • Fax: 386-362-1142

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: MR. LAVELLE HARDIN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 615-344-8203