Provider Demographics
NPI:1174674691
Name:PINE LAKE INTENSITY-MODULATED
Entity Type:Organization
Organization Name:PINE LAKE INTENSITY-MODULATED
Other - Org Name:PINE LAKE IMRT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-327-7300
Mailing Address - Street 1:3901 PINE LAKE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5497
Mailing Address - Country:US
Mailing Address - Phone:402-481-6090
Mailing Address - Fax:
Practice Address - Street 1:3901 PINE LAKE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-481-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation