VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC

Provider Demographics

• NPI: 1437102092
• Name: VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC
• Entity Type: Organization
• Organization Name: VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC
• Authorized Official - Title/Position: CMO
• Authorized Official - Prefix: DR
• Authorized Official - First Name: LESLIE
• Authorized Official - Middle Name: E
• Authorized Official - Last Name: BOTNICK
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 310-335-4065
• Mailing Address - Street 1: PO BOX 10050
• Mailing Address - City: MANHATTAN BEACH
• Mailing Address - State: CA
• Mailing Address - Zip Code: 90267-7550
• Mailing Address - Country: US
• Mailing Address - Phone: 310-416-8956
• Mailing Address - Fax: 310-536-9123
• Practice Address - Street 1: 1500 ROSECRANS AVE
• Practice Address - Street 2: 400
• Practice Address - City: MANHATTAN BEACH
• Practice Address - State: CA
• Practice Address - Zip Code: 90266-3763
• Practice Address - Country: US
• Practice Address - Phone: 310-335-4056
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-05-17
• Last Update Date: 2014-03-06

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	174400000X	Other Service Providers	Specialist		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	CH4367	Other	RR MEDICARE ST. JUDE
CA	GR0013797	Medicaid
CA	GR0013798	Medicaid
CA	GR0013792	Medicaid
CA	GR0013793	Medicaid
CA	GR001379A	Medicaid
CA	GR0013791	Medicaid
CA	GR0013794	Medicaid
CA	GR0013796	Medicaid
CA	CJ5668	Other	RR MEDICARE RIVERSIDE
CA	GR001379C	Medicaid
CA	GR001379F	Medicaid
CA	CR0476	Other	RR MEDICARE PSJ
CA	GR001379E	Medicaid
CA	CP3272	Other	RRMEDICARE SJHC
CA	DD9966	Other	RR MEDICARE EL CENTRO
CA	GR0013790	Medicaid
CA	GR0013799	Medicaid
CA	GR001379B	Medicaid
CA	GR001379D	Medicaid
CA	ZZZ20940Z	Medicare PIN
CA	W7769C	Medicare PIN
CA	CR0476	Other	RR MEDICARE PSJ
CA	GR0013799	Medicaid
CA	HW7769D	Medicare PIN
CA	ZZZ22552Z	Medicare PIN
CA	ZZZ28846Z	Medicare PIN
CA	ZZZ21178Z	Medicare PIN
CA	HW7769I	Medicare PIN
CA	HW7769F	Medicare PIN
CA	HW7769B	Medicare PIN
CA	DD9966	Other	RR MEDICARE EL CENTRO
CA	GR001379B	Medicaid
CA	GR0013798	Medicaid
CA	GR0013796	Medicaid
CA	GR0013792	Medicaid
CA	HW7769C	Medicare PIN
CA	HW7769H	Medicare PIN