Provider Demographics
NPI:1710967344
Name:PALMS WEST RADIATION THERAPY, LLC
Entity Type:Organization
Organization Name:PALMS WEST RADIATION THERAPY, LLC
Other - Org Name:PALMS WEST RADIATION THERAPY REGIONAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-784-9008
Mailing Address - Street 1:12993 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9215
Mailing Address - Country:US
Mailing Address - Phone:561-784-9008
Mailing Address - Fax:561-784-0905
Practice Address - Street 1:12993 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9215
Practice Address - Country:US
Practice Address - Phone:561-784-9008
Practice Address - Fax:561-784-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3164Medicare PIN