Provider Demographics
NPI:1043671241
Name:CCCNF - LAKE BUTLER, LLC
Entity Type:Organization
Organization Name:CCCNF - LAKE BUTLER, LLC
Other - Org Name:FL DEPT OF CORRECTIONS - RMC CANCER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:M
Authorized Official - Last Name:BITTING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-783-1253
Mailing Address - Street 1:104 WOODMONT BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2245
Mailing Address - Country:US
Mailing Address - Phone:615-467-7400
Mailing Address - Fax:615-467-7401
Practice Address - Street 1:7765 S COUNTY ROAD 231
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-5721
Practice Address - Country:US
Practice Address - Phone:386-496-0900
Practice Address - Fax:386-496-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJR457070002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRAM LICENSE 4226-1OtherRADIOACTIVE MATERIAL LICENSE