Provider Demographics
NPI:1821028804
Name:SAND LAKE CANCER CENTER
Entity Type:Organization
Organization Name:SAND LAKE CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-351-1002
Mailing Address - Street 1:7301 STONEROCK CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8002
Mailing Address - Country:US
Mailing Address - Phone:407-351-1002
Mailing Address - Fax:407-351-1119
Practice Address - Street 1:7301 STONEROCK CIRCLE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:407-351-1002
Practice Address - Fax:407-351-1096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAND LAKE CANCER CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBH45004601835X0200X
FL261QI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty
No1835X0200XPharmacy Service ProvidersPharmacistOncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255280900Medicaid
FL5821980001Medicare NSC
FLK9074Medicare PIN