Provider Demographics
NPI:1023485679
Name:SAND LAKE CANCER CENTER, PA
Entity type:Organization
Organization Name:SAND LAKE CANCER CENTER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:N
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:32819-8004
Mailing Address - Country:US
Mailing Address - Phone:407-351-1002
Mailing Address - Fax:407-745-3101
Practice Address - Street 1:7300 SANDLAKE COMMONS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8050
Practice Address - Country:US
Practice Address - Phone:407-351-1002
Practice Address - Fax:407-745-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73340174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9074Medicare PIN