Healthcare Provider Details

I. General information

NPI: 1932028800
Provider Name (Legal Business Name): SOUTH LAKE HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 CITRUS TOWER BLVD STE 101
CLERMONT FL
34711-1943
US

IV. Provider business mailing address

1414 KUHL AVE
ORLANDO FL
32806-2008
US

V. Phone/Fax

Practice location:
  • Phone: 352-536-8791
  • Fax:
Mailing address:
  • Phone: 321-841-5111
  • Fax: 407-650-3785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: JOHN ENOCH MILLER
Title or Position: SVP OF FINANCE
Credential:
Phone: 321-843-3180