Provider Demographics
NPI:1770565178
Name:SAND LAKE IMAGING LLLP
Entity type:Organization
Organization Name:SAND LAKE IMAGING LLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, RCM
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-674-7933
Mailing Address - Street 1:PO BOX 161527
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-1527
Mailing Address - Country:US
Mailing Address - Phone:866-674-7933
Mailing Address - Fax:
Practice Address - Street 1:9350 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7319
Practice Address - Country:US
Practice Address - Phone:407-363-2772
Practice Address - Fax:407-745-2844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-19
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2904OtherBC BS OF FLORIDA
DD2395OtherRAILROAD MEDICARE
FL34896Medicare ID - Type Unspecified