Healthcare Provider Details

I. General information

NPI: 1235530957
Provider Name (Legal Business Name): VANTAGE CANCER CARE NETWORK OF ILLINOIS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17750 SOUTH KEDZIE AVENUE
HAZEL CREST IL
60429-2047
US

IV. Provider business mailing address

1500 ROSECRANS AVENUE SUITE 400
MANHATTAN BEACH CA
90266-3707
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-9995
  • Fax:
Mailing address:
  • Phone: 310-335-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESLIE E. BOTNICK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-595-5769