Provider Demographics
NPI:1346561289
Name:21ST CENTURY ONCOLOGY LLC
Entity Type:Organization
Organization Name:21ST CENTURY ONCOLOGY LLC
Other - Org Name:OKALOOSA-WALTON UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COMMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7277
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:131 E REDSTONE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5326
Practice Address - Country:US
Practice Address - Phone:850-682-6333
Practice Address - Fax:850-682-0865
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIATION THERAPY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-15
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77215MMedicare PIN
FL77215CMedicare PIN