| Entity Name: | PORT ST. LUCIE PAIN MANAGEMENT, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 Sep 2006 (18 years ago) |
| Document Number: | L06000087123 |
| FEI/EIN Number | 205665242 |
| Mail Address: | 907 N. FEDERAL HWY, BOYNTON BEACH, FL, 33435, US |
| Address: | 8235 SOUTH US HIGHWAY 1, PORT ST. LUCIE, FL, 34952, US |
| ZIP code: | 34952 |
| County: | St. Lucie |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1528277670 | 2007-05-22 | 2020-10-28 | 8235 S US HIGHWAY 1, PORT ST LUCIE, FL, 349522848, US | 8235 SOUTH US HWY 1, PORT ST. LUCIE, FL, 34952, US | |||||||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 772-335-7246 |
| Fax | 7723357202 |
Authorized person
| Name | DARLENE VANCE |
| Role | PRACTICE ADMINISTRATOR |
| Phone | 7723357246 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| Is Primary | No |
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QP3300X - Pain Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICARE ID |
| Number | 15198A |
| State | FL |
| Issuer | UPIN |
| Number | E32589 |
| State | FL |
| Issuer | CAQH |
| Number | 10719333 |
| Name | Role | Address |
|---|---|---|
| ROGERS ANTHONY G | Agent | 907 N. Federal Hwy, Boynton Beach, FL, 33435 |
| Name | Role | Address |
|---|---|---|
| Rogers Anthony G | Director | 907 N. Federal Hwy, Boynton Beach, FL, 33435 |
| Name | Role | Address |
|---|---|---|
| ROGERS ANTHONY J | Officer | 907 N. FEDERAL HWY, BOYNTON BEACH, FL, 33435 |
| ROGERS MICHAEL A | Officer | 907 N. FEDERAL HWY, BOYNTON BEACH, FL, 33435 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000121185 | PORT ST LUCIE PAIN & MEDICAL INSTITUTE | ACTIVE | 2024-09-27 | 2029-12-31 | No data | 4401 N ANDREWS AVE, OAKLAND PARK, FL, 33309 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2024-03-25 | 907 N. Federal Hwy, Boynton Beach, FL 33435 | No data |
| CHANGE OF MAILING ADDRESS | 2018-09-25 | 8235 SOUTH US HIGHWAY 1, PORT ST. LUCIE, FL 34952 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-04-25 | 8235 SOUTH US HIGHWAY 1, PORT ST. LUCIE, FL 34952 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-04-29 | ROGERS, ANTHONY G | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J13001654418 | TERMINATED | 1000000547662 | ST LUCIE | 2013-10-17 | 2033-11-07 | $ 330.00 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, FORT PIERCE SERVICE CENTER, 337 N US HIGHWAY 1 STE 207-B, FORT PIERCE FL349504255 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-25 |
| ANNUAL REPORT | 2023-04-04 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-03-16 |
| ANNUAL REPORT | 2020-06-08 |
| ANNUAL REPORT | 2019-03-19 |
| ANNUAL REPORT | 2018-04-25 |
| ANNUAL REPORT | 2017-04-18 |
| ANNUAL REPORT | 2016-03-07 |
| ANNUAL REPORT | 2015-04-20 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
