Provider Demographics
NPI:1619166568
Name:S.A.C. PRIMARY CARE LLC
Entity Type:Organization
Organization Name:S.A.C. PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER OF LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:AVA
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-250-3112
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-0160
Mailing Address - Country:US
Mailing Address - Phone:352-589-5890
Mailing Address - Fax:352-589-2589
Practice Address - Street 1:2000 PREVATT ST
Practice Address - Street 2:SUITE B2
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6149
Practice Address - Country:US
Practice Address - Phone:352-589-5890
Practice Address - Fax:352-589-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8237261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH08354Medicare UPIN
FLE5014BMedicare PIN