Provider Demographics
NPI:1336187988
Name:SONSHINE AMBULATORY CARE CENTER
Entity Type:Organization
Organization Name:SONSHINE AMBULATORY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-308-0900
Mailing Address - Street 1:1405 SE GOLDTREE DR
Mailing Address - Street 2:SUITE # C
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7563
Mailing Address - Country:US
Mailing Address - Phone:772-380-0900
Mailing Address - Fax:
Practice Address - Street 1:1405 SE GOLDTREE DR
Practice Address - Street 2:SUITE # C
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7563
Practice Address - Country:US
Practice Address - Phone:772-380-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8310208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI03169Medicare UPIN