=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710967344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMS WEST RADIATION THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2006
-----------------------------------------------------
Last Update Date | 09/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12993 SOUTHERN BLVD
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-784-9008
-----------------------------------------------------
Fax | 561-784-0905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12993 SOUTHERN BLVD
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-784-9008
-----------------------------------------------------
Fax | 561-784-0905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL K. WING
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-784-9008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------