| Entity Name: | SOUTH LAKE OBSTETRICS & GYNECOLOGY, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 13 Feb 2002 (23 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 14 Feb 2002 (23 years ago) |
| Document Number: | L02000003505 |
| FEI/EIN Number | 030397724 |
| Address: | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL, 34711, US |
| Mail Address: | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL, 34711, US |
| ZIP code: | 34711 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1497754121 | 2005-07-15 | 2024-03-13 | 1900 DON WICKHAM DR STE 120, CLERMONT, FL, 347111980, US | 1900 DON WICKHAM DR STE 120, CLERMONT, FL, 347111980, US | |||||||||||||||||||||||||
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| Phone | +1 352-241-7050 |
| Fax | 3522417035 |
Authorized person
| Name | MR. MATTHEW STEPHAN CASAVANT |
| Role | OWNER |
| Phone | 3214368371 |
Taxonomy
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | OS8678 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 264093700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CASAVANT MATTHEW | Agent | 16410 LAKESHORE DRIVE, MINNEOLA, FL, 34715 |
| Name | Role | Address |
|---|---|---|
| CASAVANT MATTHEW S | Managing Member | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL, 34711 |
| PRESTON-CASAVANT SHAWN N | Managing Member | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL, 34711 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000086437 | SOUTH LAKE MEDICAL SPA | ACTIVE | 2021-06-29 | 2026-12-31 | No data | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL, 34711 |
| G15000028706 | THE MEN'S CLINIC | EXPIRED | 2015-03-19 | 2020-12-31 | No data | 1900 DON WICKHAM DRIVE, STE. 120, CLERMONT, FL, 34711 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2017-04-11 | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL 34711 | No data |
| CHANGE OF MAILING ADDRESS | 2011-04-19 | 1900 DON WICKHAM DRIVE, SUITE 120, CLERMONT, FL 34711 | No data |
| REGISTERED AGENT NAME CHANGED | 2009-04-21 | CASAVANT, MATTHEW | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2009-04-21 | 16410 LAKESHORE DRIVE, MINNEOLA, FL 34715 | No data |
| AMENDMENT | 2002-02-14 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-18 |
| ANNUAL REPORT | 2023-03-13 |
| ANNUAL REPORT | 2022-04-07 |
| ANNUAL REPORT | 2021-03-21 |
| ANNUAL REPORT | 2020-03-24 |
| ANNUAL REPORT | 2019-04-29 |
| ANNUAL REPORT | 2018-04-02 |
| ANNUAL REPORT | 2017-04-11 |
| ANNUAL REPORT | 2016-04-12 |
| ANNUAL REPORT | 2015-02-25 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
