Provider Demographics
NPI:1972906873
Name:VANTAGE CANCER CARE NETWORK OF NEW MEXICO, LLC
Entity Type:Organization
Organization Name:VANTAGE CANCER CARE NETWORK OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:UDICIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:ESQUIRE
Authorized Official - Phone:610-519-0550
Mailing Address - Street 1:1500 ROSECRANS AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3763
Mailing Address - Country:US
Mailing Address - Phone:310-335-4000
Mailing Address - Fax:
Practice Address - Street 1:1500 ROSECRANS AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-3763
Practice Address - Country:US
Practice Address - Phone:310-335-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANTAGE CANCER CARE NETWORKS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-06
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty