MEDICARE: CYBERKNIFE OF SOUTHERN CALIFORNIA AT VISTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QX0203X	Radiation Oncology Clinic/Center

General Provider Information

NPI Number	:	1245415538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CYBERKNIFE OF SOUTHERN CALIFORNIA AT VISTA

Provider Business Mailing Address
First Line	:	902 SYCAMORE AVE
Second Line	:	SUITE 100
City	:	VISTA
State	:	CA
Zip	:	92081-7879
Country	:	US
Telephone Number	:	760-599-9545
Fax Number	:	760-599-9549

Provider Business Practice Location Address
First Line	:	902 SYCAMORE AVE
Second Line	:	SUITE 100
City	:	VISTA
State	:	CA
Zip	:	92081-7879
Country	:	US
Telephone Number	:	760-599-9545
Fax Number	:	760-599-9549

Authorized Official
Title or Position	:	MANAGER
Name	:	ELIZABETH N BOURBEAU
Credential	:
Telephone Number	:	760-599-9545

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	01/04/2008

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