Provider Demographics
NPI:1265509657
Name:ONCOLOGY THERAPIES OF VISTA MEDICAL GROUP, INC
Entity type:Organization
Organization Name:ONCOLOGY THERAPIES OF VISTA MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOURBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-599-9545
Mailing Address - Street 1:916 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7815
Mailing Address - Country:US
Mailing Address - Phone:760-599-9545
Mailing Address - Fax:760-599-9549
Practice Address - Street 1:916 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7815
Practice Address - Country:US
Practice Address - Phone:760-599-9545
Practice Address - Fax:760-599-9549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A42436A0Medicaid
CA00A537410Medicaid
CA00A830540Medicaid
CA00G676470Medicaid
CAW15047Medicare PIN