| Entity Name: | BURNT STORE FAMILY MEDICINE, P.L. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 30 Apr 2002 (23 years ago) |
| Document Number: | L02000010987 |
| FEI/EIN Number | 020609414 |
| Mail Address: | C/O DAVID A. HOLMES, 99 NESBIT STREET, PUNTA GORDA, FL, 33950 |
| Address: | 100 MADRID BLVD., SUITE 513, PUNTA GORDA, FL, 33950 |
| ZIP code: | 33950 |
| County: | Charlotte |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1164739421 | 2010-09-08 | 2011-06-23 | 100 MADRID BLVD, SUITE 513, PUNTA GORDA, FL, 339507968, US | 100 MADRID BLVD, SUITE 513, PUNTA GORDA, FL, 339507968, US | |||||||||||||||||||
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| Phone | +1 941-505-0974 |
| Fax | 9415058517 |
Authorized person
| Name | GORDON WANG |
| Role | OWNER |
| Phone | 9415050974 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | ME0072508 |
| State | FL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| HOLMES DAVID AEsq. | Agent | FARR LAW FIRM P.A., PUNTA GORDA, FL, 33950 |
| Name | Role | Address |
|---|---|---|
| WANG GORDON | Manager | 100 MADRID BOULEVARD SUITE 513, PUNTA GORDA, FL, 33950 |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
