| Entity Name: | FAMILY HEALTH CENTER AT PORT ST JOHN LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 Nov 2007 (17 years ago) |
| Document Number: | L07000111602 |
| FEI/EIN Number | 261350798 |
| Address: | 3740 CURTIS BLVD, SUITE 108, COCOA, FL, 32927 |
| Mail Address: | 3740 CURTIS BLVD, SUITE 108, COCOA, FL, 32927 |
| ZIP code: | 32927 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1851575377 | 2007-12-19 | 2013-12-03 | 3740 CURTIS BLVD, SUITE 108, COCOA, FL, 329273962, US | 3740 CURTIS BLVD, SUITE 108, COCOA, FL, 329273962, US | |||||||||||||||||||||||||
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| Phone | +1 321-633-5500 |
| Fax | 3216335566 |
Authorized person
| Name | DR. JANIS G BLACK |
| Role | PHYSICIAN/OWNER |
| Phone | 3216335500 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | OS9694 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2753011400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BLACK JANIS G | Agent | 5126 ROYAL PADDOCK WAY, MERRIT ISLAND, FL, 32953 |
| Name | Role | Address |
|---|---|---|
| BLACK JANIS G | Managing Member | 5126 ROYAL PADDOCK WAY, MERRITT ISLAND, FL, 32953 |
| BLACK JOHN T | Managing Member | 5126 ROYAL PADDOCK WAY, MERRITT ISLAND, FL, 32953 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000067986 | FAMILY HEALTH CENTER AT CHICKASAW TRAIL | EXPIRED | 2011-07-06 | 2016-12-31 | No data | 540 S CHICKASAW TRAIL, ORLANDO, FL, 32825 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-04-03 |
| ANNUAL REPORT | 2022-04-06 |
| ANNUAL REPORT | 2021-04-08 |
| ANNUAL REPORT | 2020-03-17 |
| ANNUAL REPORT | 2019-05-11 |
| ANNUAL REPORT | 2018-03-01 |
| ANNUAL REPORT | 2017-07-03 |
| ANNUAL REPORT | 2016-04-12 |
| ANNUAL REPORT | 2015-04-23 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
