Basic Information
Provider Information | |||||||||
NPI: | 1770565178 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAND LAKE IMAGING LLLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 161527 | ||||||||
Address2: |   | ||||||||
City: | ALTAMONTE SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 327161527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8666747933 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9350 TURKEY LAKE RD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328197319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073632772 | ||||||||
FaxNumber: | 4077452844 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2005 | ||||||||
LastUpdateDate: | 01/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLMAN | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | SR. DIRECTOR, RCM | ||||||||
AuthorizedOfficialTelephone: | 8666747933 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | V2904 | 01 | FL | BC BS OF FLORIDA | OTHER | DD2395 | 01 |   | RAILROAD MEDICARE | OTHER |