Provider Demographics
NPI:1437287117
Name:JOHN WAYNE CANCER INSTITUTE
Entity Type:Organization
Organization Name:JOHN WAYNE CANCER INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-449-5253
Mailing Address - Street 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-449-5253
Mailing Address - Fax:
Practice Address - Street 1:1328 22ND ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2032
Practice Address - Country:US
Practice Address - Phone:310-449-5253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2086X0206X
CA332B00000X332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0889720001Medicare ID - Type Unspecified
CABG404AMedicare PIN