1528055423 NPI number — CANCER CARE ASSOCIATES MEDICAL GROUP INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528055423 NPI number — CANCER CARE ASSOCIATES MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER CARE ASSOCIATES MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CANCER CARE ASSOCIATES CLINCAL LABORATORY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528055423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 N PROSPECT AVE
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
REDONDO BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90277-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-750-3300
Provider Business Mailing Address Fax Number:
310-750-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23550 HAWTHORNE BLVD
Provider Second Line Business Practice Location Address:
BUILDING 1, SUITE #160
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90505-4731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-303-7920
Provider Business Practice Location Address Fax Number:
310-303-7910
Provider Enumeration Date:
10/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CO OWNER PRESIDENT
Authorized Official Telephone Number:
310-750-3300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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