Organization
NORTH FLORIDA CANCER CENTER LIVE OAK LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LAVELLE HARDIN (CREDENTIALING COORDINATOR)
(615) 344-8203
Entity
Organization
Contact information
Practice address
1500 OHIO AVE N, LIVE OAK, FL 32064-4820
(386) 362-1174
(386) 362-1142
Mailing address
1500 OHIO AVE N, LIVE OAK, FL 32064-4820
(386) 362-1174
(386) 362-1142
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DD1688
RR MEDICARE
FL
Enumeration date
09/30/2005
Last updated
03/18/2008
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