Basic Information
| Provider Information | |||||||||
| NPI: | 1366994675 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL CENTER OF CENTRAL FLORIDA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3221 S FLORIDA AVE STE A | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635770303 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2016 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | VOLLMER | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8635770303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | AS14960903 | 05 | FL | MEDICAID |