=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982083093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIATION ONCOLOGY TECHNICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 05/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 E COLORADO ST
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91205-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-500-5885
-----------------------------------------------------
Fax | 818-241-2946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 E COLORADO ST
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91205-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-500-5885
-----------------------------------------------------
Fax | 818-241-2946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SUNDERA V. ARIATHURAI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-500-5885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | A33601
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------