Provider Demographics
NPI:1609993666
Name:FAMILY PRACTICE CENTER OF SANFORD PA
Entity type:Organization
Organization Name:FAMILY PRACTICE CENTER OF SANFORD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-322-6341
Mailing Address - Street 1:712 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-4232
Mailing Address - Country:US
Mailing Address - Phone:407-322-6341
Mailing Address - Fax:
Practice Address - Street 1:712 W 25TH ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-4232
Practice Address - Country:US
Practice Address - Phone:407-322-6341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99331OtherBCB GRP BILL PROVIDER NUM
FL99331OtherBCB GRP BILL PROVIDER NUM