| Entity Name: | LAKE MARY PSYCHIATRIC SERVICES, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 20 Jan 2005 (20 years ago) |
| Date of dissolution: | 26 Sep 2008 (16 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 26 Sep 2008 (16 years ago) |
| Document Number: | L05000006010 |
| FEI/EIN Number | NOT APPLICABLE |
| Address: | 101 TIMBERLACHEN CIRCLE, SUITE 201, LAKE MARY, FL, 32746, US |
| Mail Address: | 1332 CHESSINGTON CIRCLE, HEATHROW, FL, 32746, US |
| ZIP code: | 32746 |
| County: | Seminole |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1285679902 | 2006-06-17 | 2020-08-22 | 101 TIMBERLACHEN CIR, SUITE 201, LAKE MARY, FL, 327466124, US | 101 TIMBERLACHEN CIR, SUITE 201, LAKE MARY, FL, 327466124, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 407-330-5818 |
| Fax | 4073305820 |
Authorized person
| Name | MANUEL R. MOTA-CASTILLO |
| Role | PSYCHIATRIC/MEDICAL DIRECTOR |
| Phone | 4073305818 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME-82747 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | AETNA |
| Number | 7771009 |
| State | FL |
| Issuer | MENTAL HEALTH NETWORK |
| Number | 111973343307 |
| State | FL |
| Issuer | HARMONY BEHAVIORAL HEALTH |
| Number | 272693 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 52339 |
| State | FL |
| Issuer | VALUE OPTIONS |
| Number | 543580 |
| State | FL |
| Issuer | AMERIGROUP |
| Number | 110962 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MOTA-CASTILLO MANUEL R | Agent | 1332 CHESSINGTON CIRCLE, HEATHROW, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| MOTA-CASTILLO MANUEL R | Manager | 1332 CHESSINGTON CIRCLE, HEATHROW, FL, 32746 |
| SALJA-MOTA ROSA M | Manager | 1332 CHESSINGTON CIRCLE, HEATHROW, FL, 32746 |
| MEDAL JEANETTE | Manager | 101 TIMBERLACHEN CIRCLE, LAKE MARY, FL, 32746 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2008-09-26 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2007-01-04 |
| ANNUAL REPORT | 2006-01-03 |
| Florida Limited Liability | 2005-01-20 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
