MEDICARE: SAND LAKE SURGERY CENTER, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center		FL

General Provider Information

NPI Number	:	1457545980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAND LAKE SURGERY CENTER, LP

Provider Business Mailing Address
First Line	:	7477 SAND LAKE COMMONS BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-8034
Country	:	US
Telephone Number	:	407-264-9633
Fax Number	:	407-264-9959

Provider Business Practice Location Address
First Line	:	7477 SAND LAKE COMMONS BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-8034
Country	:	US
Telephone Number	:	407-264-9633
Fax Number	:	407-264-9959

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. CHERYL MODICA
Credential	:
Telephone Number	:	407-264-9633

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	03/31/2010

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