Healthcare Provider Details

I. General information

NPI: 1295820900
Provider Name (Legal Business Name): LAKESHORE AREA RADIATION ONCOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12642 RILEY ST
HOLLAND MI
49424-9202
US

IV. Provider business mailing address

12642 RILEY ST
HOLLAND MI
49424-9202
US

V. Phone/Fax

Practice location:
  • Phone: 616-355-3876
  • Fax: 616-786-0255
Mailing address:
  • Phone: 616-355-3876
  • Fax: 616-786-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN POWERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 616-772-7513