| Entity Name: | MELBOURNE PODIATRY ASSOCIATES, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 01 Jul 1981 (44 years ago) |
| Document Number: | 691673 |
| FEI/EIN Number | 592091713 |
| Address: | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901, US |
| Mail Address: | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901, US |
| ZIP code: | 32901 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1174506877 | 2005-11-28 | 2023-05-12 | 1515 DR MARTIN LUTHER KING JR BLVD, MELBOURNE, FL, 329012946, US | 1515 DR MARTIN LUTHER KING JR BLVD, MELBOURNE, FL, 329012946, US | |||||||||||||||||||||||||||
|
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| Phone | +1 321-723-3500 |
| Fax | 3217231945 |
Authorized person
| Name | DR. JARED B MOYLES |
| Role | PRESIDENT |
| Phone | 3217233500 |
Taxonomy
| Taxonomy Code | 213E00000X - Podiatrist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 72224 |
| State | FL |
| Issuer | MEDICAID |
| Number | 041009800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FRESE GARY BEsq. | Agent | 2200 FRONT STREET, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| MOYLES JARED B | President | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| WILSON THOMAS | Director | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| WILSON JESSICA | Director | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| MOYLES JARED B | Director | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| WILSON THOMAS | Vice President | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| WILSON JESSICA | Vice President | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| WILSON THOMAS | Secretary | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| WILSON JESSICA | Treasurer | 1515 Dr. Martin Luther King Jr. Blvd, MELBOURNE, FL, 32901 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G05032900284 | MELBOURNE PODIATRY ASSOCIATES | ACTIVE | 2005-02-01 | 2025-12-31 | No data | 1515 DR MARTIN LUTHER KING JR BLVD, MELBOURNE, FL, 32901 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| NAME CHANGE AMENDMENT | 2018-04-03 | MELBOURNE PODIATRY ASSOCIATES, P.A. | No data |
| CANCEL ADM DISS/REV | 2008-11-12 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2008-09-26 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
