Provider Demographics
NPI:1417155730
Name:MINIER WATERFORD LAKES LLC
Entity Type:Organization
Organization Name:MINIER WATERFORD LAKES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOAZ
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-257-5782
Mailing Address - Street 1:12301 LAKE UNDERHILL RD STE 118
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4510
Mailing Address - Country:US
Mailing Address - Phone:407-249-8870
Mailing Address - Fax:407-249-8871
Practice Address - Street 1:12301 LAKE UNDERHILL RD STE 118
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4510
Practice Address - Country:US
Practice Address - Phone:407-249-8870
Practice Address - Fax:407-249-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAJ379Medicare PIN