MEDICARE: VANTAGE CANCER CARE - CALIFORNIA

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	2085R0001X	Radiation Oncology Physician
2	207RX0202X	Medical Oncology Physician

General Provider Information

NPI Number	:	1689077554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANTAGE CANCER CARE - CALIFORNIA

Provider Business Mailing Address
First Line	:	1500 ROSECRANS AVE
Second Line	:	SUITE 400
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-3763
Country	:	US
Telephone Number	:	310-335-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 ROSECRANS AVE
Second Line	:	SUITE 400
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-3763
Country	:	US
Telephone Number	:	310-335-4000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LESLIE E. BOTNICK
Credential	:	M.D.
Telephone Number	:	323-595-5769

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	10/06/2014

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