| Entity Name: | LAKE MARY SURGERY CENTER, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 16 Sep 2002 (22 years ago) |
| Document Number: | L02000024087 |
| FEI/EIN Number | 134215228 |
| Address: | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027, US |
| Mail Address: | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1174530752 | 2006-08-03 | 2023-02-21 | 460 SAINT CHARLES CT, LAKE MARY, FL, 327462103, US | 460 SAINT CHARLES CT, LAKE MARY, FL, 327462103, US | |||||||||||||||||||||||||
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| Phone | +1 407-585-0260 |
| Fax | 4075850264 |
Authorized person
| Name | JENNIFER BOYD BALDOCK |
| Role | OFFICER AND AUTHORIZED OFFICIAL |
| Phone | 6152345954 |
Taxonomy
| Taxonomy Code | 261QA1903X - Ambulatory Surgical Clinic/Center |
| License Number | 1204 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 075897300 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| BALDOCK JENNIFER | Manager | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027 |
| Name | Role | Address |
|---|---|---|
| O'Brien Jeff | vp | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027 |
| Doherty Dave | vp | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027 |
| Kennedy Brett | vp | Suite 600 340 Seven Springs Way, Brentwood, TN, 37027 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2008-11-18 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
