Provider Demographics
NPI:1558590778
Name:LAKEWOOD RANCH PREMIER CARE
Entity Type:Organization
Organization Name:LAKEWOOD RANCH PREMIER CARE
Other - Org Name:(DBA) SARASOTA CENTER FOR FAMILY HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERSHORIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-364-4411
Mailing Address - Street 1:6120 53RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203
Mailing Address - Country:US
Mailing Address - Phone:941-364-4411
Mailing Address - Fax:941-364-4466
Practice Address - Street 1:6120 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203
Practice Address - Country:US
Practice Address - Phone:941-364-4411
Practice Address - Fax:941-364-4466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEWOOD RANCH PREMIER CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-09
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0005MOtherBCBS OF FL
FL001317700Medicaid
FL=========OtherEIN
FL=========OtherEIN