Healthcare Provider Details

I. General information

NPI: 1750463543
Provider Name (Legal Business Name): LAFAYETTE CANCER CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL STE 135
LAFAYETTE IN
47905-5760
US

IV. Provider business mailing address

1345 UNITY PL STE 135
LAFAYETTE IN
47905-5760
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5050
  • Fax: 765-446-5119
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number01045452A
License Number StateIN

VIII. Authorized Official

Name: SUSAN GRAY
Title or Position: PRACTICE ADMIN
Credential:
Phone: 765-446-5050