| Entity Name: | JOHNSON DIALYSIS CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 27 Feb 2006 (19 years ago) |
| Document Number: | L06000020877 |
| FEI/EIN Number | 205166181 |
| Address: | 7769 Johnson Street, Pembroke Pines, FL, 33024, US |
| Mail Address: | 7769 Johnson Street, Pembroke Pines, FL, 33024, US |
| ZIP code: | 33024 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104019447 | 2007-08-21 | 2020-08-11 | 7769 JOHNSON ST, PEMBROKE PINES, FL, 330246856, US | 7769 JOHNSON ST, PEMBROKE PINES, FL, 330246856, US | |||||||||||||||||||||
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| Phone | +1 954-962-9640 |
| Fax | 9549629641 |
Authorized person
| Name | KEITH CARRASCO |
| Role | ADMINISTRATOR |
| Phone | 9549629640 |
Taxonomy
| Taxonomy Code | 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 000791100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Reyes Evelyn | Agent | 7769 JOHNSON STREET, PEMBROKE PINES, FL, 33024 |
| Name | Role | Address |
|---|---|---|
| Tan-Carrasco Grace | Manager | 220 NW 151 Avenue, Pembroke Pines, FL, 33028 |
| Siao Gloria | Manager | 220 NW 151 Avenue, Pembroke Pines, FL, 33028 |
| Reyes Evelyn | Manager | 800 SW 191 Terrace, Pembroke Pines, FL, 33029 |
| Gulati Manjit | Manager | 10726 Charleston Place, Cooper City, FL, 33026 |
| YAP EMELY | Manager | 5435 NW 95th Avenue, Sunrise, FL, 33351 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2024-01-25 | 7769 JOHNSON STREET, PEMBROKE PINES, FL 33024 | No data |
| REGISTERED AGENT NAME CHANGED | 2023-01-13 | Reyes, Evelyn | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-01-15 | 7769 Johnson Street, Pembroke Pines, FL 33024 | No data |
| CHANGE OF MAILING ADDRESS | 2020-01-15 | 7769 Johnson Street, Pembroke Pines, FL 33024 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-25 |
| ANNUAL REPORT | 2023-01-13 |
| ANNUAL REPORT | 2022-01-21 |
| ANNUAL REPORT | 2021-01-08 |
| ANNUAL REPORT | 2020-01-15 |
| AMENDED ANNUAL REPORT | 2019-05-18 |
| ANNUAL REPORT | 2019-05-01 |
| ANNUAL REPORT | 2018-03-01 |
| ANNUAL REPORT | 2017-02-18 |
| ANNUAL REPORT | 2016-02-15 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
