Provider Demographics
NPI:1629257860
Name:WEISENTHAL CANCER GROUP
Entity Type:Organization
Organization Name:WEISENTHAL CANCER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WEISENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:714-596-2100
Mailing Address - Street 1:16512 BURKE LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-4538
Mailing Address - Country:US
Mailing Address - Phone:714-596-2100
Mailing Address - Fax:
Practice Address - Street 1:16512 BURKE LANE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-4538
Practice Address - Country:US
Practice Address - Phone:714-596-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX558864Medicare PIN