Healthcare Provider Details

I. General information

NPI: 1336445873
Provider Name (Legal Business Name): SAND LAKE SURGICENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7477 SANDLAKE COMMONS BLVD
ORLANDO FL
32819-8034
US

IV. Provider business mailing address

7477 SANDLAKE COMMONS BLVD
ORLANDO FL
32819-8034
US

V. Phone/Fax

Practice location:
  • Phone: 407-264-9633
  • Fax: 407-264-9959
Mailing address:
  • Phone: 407-264-9633
  • Fax: 407-264-9959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1289
License Number StateFL

VIII. Authorized Official

Name: MS. CHERYL MODICA
Title or Position: ADMINISTRATOR
Credential: L.H.R.M.
Phone: 407-264-9633