| Entity Name: | HEARTLAND PEDIATRICS OF LAKE WALES, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 02 Jun 2006 (19 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 01 Jul 2020 (5 years ago) |
| Document Number: | L06000057237 |
| FEI/EIN Number | 650737449 |
| Address: | 1354 HWY 60 E, LAKE WALES, FL, 33853, US |
| Mail Address: | 1354 State Road 60 East, Lake Wales, FL, 33853, US |
| ZIP code: | 33853 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104989680 | 2006-12-18 | 2012-09-04 | 1354 STATE ROAD 60 E, LAKE WALES, FL, 338534322, US | 1354 STATE ROAD 60 E, LAKE WALES, FL, 338534322, US | |||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||
| Phone | +1 863-679-8888 |
| Fax | 8636762851 |
Authorized person
| Name | DR. RAJESWARI SONNI |
| Role | OFFICER AND MEDICAL DIRECTOR |
| Phone | 8636798888 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 21247 |
| State | FL |
| Issuer | MEDICAID |
| Number | 251469900 |
| State | FL |
| Issuer | MEDICAID |
| Number | 251469901 |
| State | FL |
| Name | Role |
|---|---|
| DEAN MEAD SERVICES, LLC | Agent |
| Name | Role | Address |
|---|---|---|
| SONNI RAJESWARI M | Manager | 1354 HWY 60 E, LAKE WALES, FL, 33853 |
| Name | Role | Address |
|---|---|---|
| HREN LAURENCE | Administrator | 1354 State Road 60 East, Lake Wales, FL, 33853 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2023-04-13 | 1354 HWY 60 E, LAKE WALES, FL 33853 | No data |
| LC STMNT OF RA/RO CHG | 2020-07-01 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2020-06-01 | DEAN MEAD SERVICES, LLC | No data |
| LC STMNT OF RA/RO CHG | 2016-12-14 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-12-14 | 420 S ORANGE AVE., SUITE 700, ORLANDO, FL 32801 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-08-22 | 1354 HWY 60 E, LAKE WALES, FL 33853 | No data |
| CONVERSION | 2006-06-02 | No data | CORPORATION WAS A CONVERSION RESULT. CONVERTING CORPORATION WAS P97000022527. CONVERSION NUMBER 100000057581 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-19 |
| ANNUAL REPORT | 2023-04-13 |
| ANNUAL REPORT | 2022-03-03 |
| ANNUAL REPORT | 2021-03-18 |
| CORLCRACHG | 2020-07-01 |
| ANNUAL REPORT | 2020-03-17 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-01-14 |
| ANNUAL REPORT | 2017-03-20 |
| CORLCRACHG | 2016-12-14 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
