MEDICARE: LAKE CITY CANCER CARE LLC

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	207RH0003X	Hematology & Oncology Physician	HCC10421	FL
2	207RX0202X	Medical Oncology Physician	HCC10421	FL
3	208800000X	Urology Physician	HCC10606	FL
4	2085R0001X	Radiation Oncology Physician	HCC8414	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396132213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE CITY CANCER CARE LLC

Provider Business Mailing Address
First Line	:	289 SW STONEGATE TER STE 103
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-628-9231

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 103
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3456
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-628-9231

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT & CFO
Name	:	CHAOQIANG LIN
Credential	:
Telephone Number	:	214-587-4079

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	02/02/2026

Similar Medicare Providers

1194795658 — SOUTHERN OPEN MRI INC
Practice Location Address:

289 SW STONEGATE TER , SUITE 102
LAKE CITY, FL
32024-3456

Practice Phone: 386-755-4788
Practice Fax: 386-755-9980

1285822981 — INTERNAL MEDICINE OF LAKE CITY PA
Practice Location Address:

289 SW STONEGATE TER , SUITE 104
LAKE CITY, FL
32024-3456

Practice Phone: 386-755-1703
Practice Fax: 386-755-1744

1982216321 — DM REHAB CORE LLC
Practice Location Address:

289 SW STONEGATE TER
LAKE CITY, FL
32024-3456

Practice Phone: 386-401-4309
Practice Fax:

1255620068 — DR. CHAD CHENOWETH M.D.
Practice Location Address:

1512 E 3115 S
SALT LAKE CITY, UT
84106-3456

Practice Phone: 801-205-4112
Practice Fax:

1518392893 — SARA MARIE MICKELSON R.D., M.B.A.
Practice Location Address:

1990 S MCCLELLAND ST APT 15
SALT LAKE CITY, UT
84105-3456

Practice Phone: 310-529-2455
Practice Fax:

1851627483 — JKA ENTERPRISES,INC
Practice Location Address:

15800 BOONES FERRY RD STE B1
LAKE OSWEGO, OR
97035-3456

Practice Phone: 503-860-4819
Practice Fax:

Directions to “LAKE CITY CANCER CARE LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.