Healthcare Provider Details

I. General information

NPI: 1336228949
Provider Name (Legal Business Name): CANCER INSTITUTE OF CAPE GIRARDEAU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOCTORS PARK SUITE B
CAPE GIRARDEAU MO
63703-4928
US

IV. Provider business mailing address

14 DOCTORS PARK SUITE B
CAPE GIRARDEAU MO
63703-4928
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-2230
  • Fax: 573-651-6499
Mailing address:
  • Phone: 573-334-2230
  • Fax: 573-651-6499

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: LESLIE LUTTRELL
Title or Position: BILLER/CODER
Credential: ROCC
Phone: 573-331-5916