=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063675734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL CENTER AT SUN N LAKE L L C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2008
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4240 SUN N LAKE BLVD SUITE 100
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33872-1986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-382-2622
-----------------------------------------------------
Fax | 863-385-2266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3609 SEBRING PKWY PMB 30
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33870-1699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-382-2622
-----------------------------------------------------
Fax | 863-385-2266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD OF MANAGERS PRESIDENT
-----------------------------------------------------
Name | DR. BAHRAM AHMADI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-715-7915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------