MEDICARE: WEISENTHAL CANCER GROUP

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	291U00000X	Clinical Medical Laboratory		CA

General Provider Information

NPI Number	:	1629257860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEISENTHAL CANCER GROUP

Provider Business Mailing Address
First Line	:	16512 BURKE LANE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-4538
Country	:	US
Telephone Number	:	714-596-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	16512 BURKE LANE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-4538
Country	:	US
Telephone Number	:	714-596-2100
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. LARRY MARK WEISENTHAL
Credential	:	M.D., PH.D.
Telephone Number	:	714-596-2100

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	01/08/2008

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