Healthcare Provider Details

I. General information

NPI: 1366694796
Provider Name (Legal Business Name): PENINSULA RAD ONC CTR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11511 CANTERWOOD BLVD STE 50
GIG HARBOR WA
98332-5816
US

IV. Provider business mailing address

4230 BRIDGEPORT WAY W STE B
UNIVERSITY PLACE WA
98466-4335
US

V. Phone/Fax

Practice location:
  • Phone: 253-779-6325
  • Fax: 253-627-8792
Mailing address:
  • Phone: 253-779-6325
  • Fax: 253-627-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateWA

VIII. Authorized Official

Name: MRS. BETTY SABLE
Title or Position: CFO
Credential:
Phone: 253-779-6325