Provider Demographics
NPI:1366694796
Name:PENINSULA RAD ONC CTR LLC
Entity type:Organization
Organization Name:PENINSULA RAD ONC CTR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SABLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-779-6325
Mailing Address - Street 1:4230 BRIDGEPORT WAY W STE B
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4335
Mailing Address - Country:US
Mailing Address - Phone:253-779-6325
Mailing Address - Fax:253-627-8792
Practice Address - Street 1:11511 CANTERWOOD BLVD STE 50
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5816
Practice Address - Country:US
Practice Address - Phone:253-779-6325
Practice Address - Fax:253-627-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0001X
WA261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7144793Medicaid
WA8949842OtherL&I CRIME VICTIMS