| Entity Name: | INTERVENTIONAL PAIN SERVICE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 11 Jul 2006 (19 years ago) |
| Last Event: | LC ARTICLE OF CORRECTION |
| Event Date Filed: | 31 Jul 2006 (19 years ago) |
| Document Number: | L06000069067 |
| FEI/EIN Number | 830462324 |
| Address: | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL, 32114, US |
| Mail Address: | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL, 32114, US |
| ZIP code: | 32114 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1689681793 | 2006-08-02 | 2020-08-22 | 201 N CLYDE MORRIS BLVD, SUITE 120, DAYTONA BEACH, FL, 321142724, US | 201 N CLYDE MORRIS BLVD, SUITE 120, DAYTONA BEACH, FL, 321142724, US | |||||||||||||||||||||||||||||||
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| Phone | +1 386-254-4029 |
| Fax | 3862544274 |
Authorized person
| Name | DR. WILLIAM ROSS MAYFIELD |
| Role | MEMBER MANAGER |
| Phone | 3862544029 |
Taxonomy
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| License Number | ME0063660 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 372693200 |
| State | FL |
| Issuer | BLUE SHIELD |
| Number | 18828 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Mayfield William RDr. | Agent | 201 N. CLYDE MORRIS BLVD., DAYTONA BEACH, FL, 32114 |
| Name | Role | Address |
|---|---|---|
| MAYFIELD WILLIAM ROSS | Managing Member | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL, 32114 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2021-04-13 | Mayfield, William R, Dr. | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-03-30 | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL 32114 | No data |
| CHANGE OF MAILING ADDRESS | 2018-03-30 | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL 32114 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-03-30 | 201 N. CLYDE MORRIS BLVD., SUITE 230, DAYTONA BEACH, FL 32114 | No data |
| LC ARTICLE OF CORRECTION | 2006-07-31 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-03-06 |
| ANNUAL REPORT | 2022-03-15 |
| ANNUAL REPORT | 2021-04-13 |
| ANNUAL REPORT | 2020-04-29 |
| ANNUAL REPORT | 2019-05-08 |
| ANNUAL REPORT | 2018-03-30 |
| ANNUAL REPORT | 2017-03-21 |
| ANNUAL REPORT | 2016-03-02 |
| ANNUAL REPORT | 2015-01-07 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
