| Entity Name: | LAKESHORE MEDICAL CARE CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 20 Jun 1989 (36 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | K96887 |
| FEI/EIN Number | 59-2953696 |
| Address: | 4570 SAN JUAN AVE., Suite 2, JACKSONVILLE, FL 32210 |
| Mail Address: | PO Box 14640, Jacksonville, FL 32238 |
| ZIP code: | 32210 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124195573 | 2006-11-29 | 2010-12-27 | 4616 SAN JUAN AVE, JACKSONVILLE, FL, 322103228, US | 4616 SAN JUAN AVE, JACKSONVILLE, FL, 322103228, US | |||||||||||||||||||||||||||
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| Phone | +1 904-384-5385 |
| Fax | 9043885838 |
Authorized person
| Name | MISS TRACY TEAGLE |
| Role | OFFICE MANAGER |
| Phone | 9043845385 |
Taxonomy
| Taxonomy Code | 305R00000X - Preferred Provider Organization |
| License Number | 0042816 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 305R00000X - Preferred Provider Organization |
| License Number | ME0018387 |
| State | FL |
| Is Primary | No |
| Name | Role | Address |
|---|---|---|
| TEAGLE, TRACY | Agent | 4570 SAN JUAN AVE., Suite 2, JACKSONVILLE, FL 32210 |
| Name | Role | Address |
|---|---|---|
| PUNYA, CHALERMCHAI MD | Director | 4570 SAN JUAN AVE., Suite 2 JACKSONVILLE, FL 32210 |
| Name | Role | Address |
|---|---|---|
| TEAGLE, TRACY | Secretary | 4570 SAN JUAN AVE., Suite 2 JACKSONVILLE, FL 32210 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2018-03-12 | 4570 SAN JUAN AVE., Suite 2, JACKSONVILLE, FL 32210 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-04-13 | 4570 SAN JUAN AVE., Suite 2, JACKSONVILLE, FL 32210 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-04-13 | 4570 SAN JUAN AVE., Suite 2, JACKSONVILLE, FL 32210 | No data |
| REGISTERED AGENT NAME CHANGED | 2008-03-27 | TEAGLE, TRACY | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2018-03-12 |
| ANNUAL REPORT | 2017-04-04 |
| ANNUAL REPORT | 2016-04-13 |
| ANNUAL REPORT | 2015-04-21 |
| ANNUAL REPORT | 2014-04-21 |
| ANNUAL REPORT | 2013-04-29 |
| ANNUAL REPORT | 2012-04-23 |
| ANNUAL REPORT | 2011-04-29 |
| ANNUAL REPORT | 2010-04-27 |
| ANNUAL REPORT | 2009-02-04 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
