| Entity Name: | INTERCOASTAL ORTHOTICS & PROSTHETICS LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 15 Feb 2005 (20 years ago) |
| Date of dissolution: | 29 Apr 2012 (13 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 29 Apr 2012 (13 years ago) |
| Document Number: | L05000015772 |
| FEI/EIN Number | 331111676 |
| Address: | 1 PELICAN DR, EDGEWATER, FL, 32141, US |
| Mail Address: | 1 PELICAN DR, EDGEWATER, FL, 32141, US |
| ZIP code: | 32141 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1083839062 | 2007-04-16 | 2009-08-03 | 1 PELICAN DR STE A, EDGEWATER, FL, 321414254, US | 1 PELICAN DR STE A, EDGEWATER, FL, 321414254, US | |||||||||||||||||||||||||
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| Phone | +1 386-409-9432 |
| Fax | 3864099433 |
Authorized person
| Name | MR. TOM HARVEY MOWERY |
| Role | PROSTHETIST, ORTHOTIST |
| Phone | 3864099432 |
Taxonomy
| Taxonomy Code | 335E00000X - Prosthetic/Orthotic Supplier |
| License Number | POR 162 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS PROVIDER # |
| Number | M2714 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MOWERY TOM H | Agent | 3500 ROCK OAK TRAIL, EDGEWATER, FL, 32141 |
| Name | Role | Address |
|---|---|---|
| MOWERY TOM H | Manager | 3500 ROCK OAK TRAIL, EDGEWATER, FL, 32141 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2012-04-29 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2010-07-08 | 3500 ROCK OAK TRAIL, EDGEWATER, FL 32141 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2009-05-22 | 1 PELICAN DR, EDGEWATER, FL 32141 | No data |
| CHANGE OF MAILING ADDRESS | 2009-05-22 | 1 PELICAN DR, EDGEWATER, FL 32141 | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2012-04-29 |
| ANNUAL REPORT | 2011-04-21 |
| ANNUAL REPORT | 2010-07-08 |
| ANNUAL REPORT | 2009-04-30 |
| ANNUAL REPORT | 2008-04-22 |
| ANNUAL REPORT | 2007-05-22 |
| ANNUAL REPORT | 2006-04-27 |
| Florida Limited Liability | 2005-02-15 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
