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General NPI Number Information
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NPI Number | 1336445873
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Entity Type | Organization
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Legal Business Name | SAND LAKE SURGICENTER LLC
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 10/05/2011
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Provider Practice Location Address
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Address Line | 7477 SANDLAKE COMMONS BLVD
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City | ORLANDO
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State | FL
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Zip | 32819-8034
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Country | US
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Telephone | 407-264-9633
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Fax | 407-264-9959
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Provider Business Mailing Address
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Address Line | 7477 SANDLAKE COMMONS BLVD
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City | ORLANDO
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State | FL
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Zip | 32819-8034
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Country | US
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Telephone | 407-264-9633
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Fax | 407-264-9959
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. CHERYL MODICA
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Credential | L.H.R.M.
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Telephone | 407-264-9633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 1289
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License Number State | FL
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