Provider Demographics
NPI:1821471533
Name:WINTER PARK CANCER CENTER, LLC
Entity Type:Organization
Organization Name:WINTER PARK CANCER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CHC
Authorized Official - Phone:949-385-5012
Mailing Address - Street 1:1561 W FAIRBANKS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4678
Mailing Address - Country:US
Mailing Address - Phone:407-478-4920
Mailing Address - Fax:
Practice Address - Street 1:1561 W FAIRBANKS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4678
Practice Address - Country:US
Practice Address - Phone:407-478-4920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty