| Entity Name: | MAGNOLIA PEDIATRICS, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 29 Aug 2007 (17 years ago) |
| Last Event: | LC AMENDMENT AND NAME CHANGE |
| Event Date Filed: | 14 Jan 2008 (17 years ago) |
| Document Number: | L07000089019 |
| FEI/EIN Number | 261101056 |
| Address: | 1140 SW BASCOM NORRIS DR, SUITE 104, LAKE CITY, FL, 32025 |
| Mail Address: | 1140 SW BASCOM NORRIS DR, SUITE 104, LAKE CITY, FL, 32025 |
| ZIP code: | 32025 |
| County: | Columbia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1356513964 | 2008-03-24 | 2012-10-05 | 1140 SW BASCOM NORRIS DR STE 104, LAKE CITY, FL, 320251329, US | 1140 SW BASCOM NORRIS DR STE 104, LAKE CITY, FL, 320251329, US | |||||||||||||||||||||||||
|
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| Phone | +1 386-719-6500 |
| Fax | 3867196503 |
Authorized person
| Name | DR. BILAL KHODR |
| Role | PROVIDER |
| Phone | 3867196500 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME72652 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | TRICARE |
| Number | 061823792 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Muenchen John R | Agent | 1140 SW Bascom Norris Drive #107, LAKE CITY, FL, 32055 |
| Name | Role | Address |
|---|---|---|
| CERVANTES STACEY | Managing Member | 129 SW INWOOD COURT, LAKE CITY, FL, 32024 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2016-04-29 | Muenchen, John R | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-04-29 | 1140 SW Bascom Norris Drive #107, LAKE CITY, FL 32055 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2008-01-30 | 1140 SW BASCOM NORRIS DR, SUITE 104, LAKE CITY, FL 32025 | No data |
| CHANGE OF MAILING ADDRESS | 2008-01-30 | 1140 SW BASCOM NORRIS DR, SUITE 104, LAKE CITY, FL 32025 | No data |
| LC AMENDMENT AND NAME CHANGE | 2008-01-14 | MAGNOLIA PEDIATRICS, L.L.C. | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-19 |
| ANNUAL REPORT | 2023-03-20 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-04-30 |
| ANNUAL REPORT | 2020-06-30 |
| ANNUAL REPORT | 2019-03-05 |
| ANNUAL REPORT | 2018-04-25 |
| ANNUAL REPORT | 2017-04-18 |
| ANNUAL REPORT | 2016-04-29 |
| ANNUAL REPORT | 2015-04-06 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
