Provider Demographics
NPI:1215703046
Name:2406 CANCER CARE LLC
Entity type:Organization
Organization Name:2406 CANCER CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-234-6473
Mailing Address - Street 1:2406 BELLEVUE RD STE 7
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2842
Mailing Address - Country:US
Mailing Address - Phone:478-272-2255
Mailing Address - Fax:
Practice Address - Street 1:1770 WATSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3632
Practice Address - Country:US
Practice Address - Phone:478-333-6961
Practice Address - Fax:478-333-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty