=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770581183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COUNTY RADIATION ONCOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2005
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 477 N EL CAMINO REAL STE D100
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-634-4300
-----------------------------------------------------
Fax | 760-632-9791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 SYCAMORE AVE
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92081-7815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-599-9545
-----------------------------------------------------
Fax | 760-599-9549
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ELIZABETH BOURBEAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-599-9545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------