| Entity Name: | FORT WALTON DIAGNOSTIC IMAGING CENTER, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 02 Feb 2001 (24 years ago) |
| Date of dissolution: | 24 Sep 2010 (14 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 24 Sep 2010 (14 years ago) |
| Document Number: | L01000001819 |
| FEI/EIN Number | 651074896 |
| Address: | 1112 HOSPITAL RD, STE C, FORT WALTON BEACH, FL, 32547 |
| Mail Address: | 1112 HOSPITAL RD, STE C, FORT WALTON BEACH, FL, 32547 |
| ZIP code: | 32547 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1619920642 | 2006-05-19 | 2020-08-22 | 1112 HOSPITAL RD, SUITE C, FORT WALTON BEACH, FL, 325476742, US | 1112 HOSPITAL RD, SUITE C, FORT WALTON BEACH, FL, 325476742, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-862-7070 |
| Fax | 8508620900 |
Authorized person
| Name | GARY MCMICHAEL |
| Role | MEMBER |
| Phone | 8508627070 |
Taxonomy
| Taxonomy Code | 261QM1300X - Multi-Specialty Clinic/Center |
| License Number | HCC4489 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 261QR0200X - Radiology Clinic/Center |
| License Number | HCC4489 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BCBS FL PROVIDER NO. |
| Number | V2837 |
| State | FL |
| Issuer | AETNA PROVIDER NO. |
| Number | 7732283 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MCMICHAEL GARY | Agent | 1112 HOSPITAL RD, FORT WALTON BEACH, FL, 32547 |
| Name | Role | Address |
|---|---|---|
| MCMICHAEL GARY W | Managing Member | 323 PAGE BACON RD #17, MARY ESTHER, FL, 32569 |
| ZACHOS KALLIOPE | Managing Member | 4154 BEACH DR, NICEVILLE, FL, 32578 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2010-09-24 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2008-05-01 | 1112 HOSPITAL RD, STE C, FORT WALTON BEACH, FL 32547 | No data |
| CHANGE OF MAILING ADDRESS | 2008-05-01 | 1112 HOSPITAL RD, STE C, FORT WALTON BEACH, FL 32547 | No data |
| REGISTERED AGENT NAME CHANGED | 2004-04-28 | MCMICHAEL, GARY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2002-04-17 | 1112 HOSPITAL RD, SUITE C, FORT WALTON BEACH, FL 32547 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2009-05-01 |
| ANNUAL REPORT | 2008-05-01 |
| ANNUAL REPORT | 2007-05-09 |
| ANNUAL REPORT | 2006-05-01 |
| ANNUAL REPORT | 2005-04-18 |
| ANNUAL REPORT | 2004-04-28 |
| ANNUAL REPORT | 2003-05-05 |
| ANNUAL REPORT | 2002-04-17 |
| Florida Limited Liabilites | 2001-02-02 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
