| Entity Name: | AVALON MEDICAL GROUP, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 14 Feb 2008 (17 years ago) |
| Document Number: | L08000016372 |
| FEI/EIN Number | 261959226 |
| Address: | 1918 LODGEPOLE DRIVE, MILTON, FL, 32583 |
| Mail Address: | PO BOX 10209, PENSACOLA, FL, 32524 |
| ZIP code: | 32583 |
| County: | Santa Rosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558531905 | 2008-03-01 | 2012-07-06 | PO BOX 10209, PENSACOLA, FL, 325240209, US | 1900 SUMMIT BLVD, PENSACOLA, FL, 325033359, US | |||||||||||||||||||||||||||||
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| Phone | +1 850-476-4200 |
| Fax | 8666840566 |
| Phone | +1 850-436-5900 |
Authorized person
| Name | MS. KATHERINE K STANLEY |
| Role | AUTHORIZED AGENT |
| Phone | 8504857341 |
Taxonomy
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD OF FLORIDA |
| Number | 00A0P |
| State | FL |
| Issuer | MEDICAID |
| Number | 001078000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| STANLEY KATHERINE K | Agent | 1918 LODGEPOLE DRIVE, MILTON, FL, 32583 |
| Name | Role | Address |
|---|---|---|
| STANLEY KATHERINE K | Manager | 1918 LODGEPOLE DR., MILTON, FL, 32583 |
| STANLEY GREGORY F | Manager | 1918 LODGEPOLE DR., MILTON, FL, 32583 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000094999 | AMG MEDICAL BUSINESS SERVICES | EXPIRED | 2011-09-26 | 2016-12-31 | No data | 6706 N. 9TH AVE, C-5, PENSACOLA, FL, 32504 |
| G08049900113 | AVALON MEDICAL GROUP, LLC | EXPIRED | 2008-02-16 | 2013-12-31 | No data | 1918 LODGEPOLE DR., MILTON, FL, 32583 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2025-01-20 | 1918 LODGEPOLE DRIVE, MILTON, FL 32583 | No data |
| CHANGE OF MAILING ADDRESS | 2011-02-25 | 1918 LODGEPOLE DRIVE, MILTON, FL 32583 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-20 |
| ANNUAL REPORT | 2024-01-07 |
| ANNUAL REPORT | 2023-01-08 |
| ANNUAL REPORT | 2022-01-23 |
| ANNUAL REPORT | 2021-01-10 |
| ANNUAL REPORT | 2020-01-11 |
| ANNUAL REPORT | 2019-01-14 |
| ANNUAL REPORT | 2018-01-04 |
| ANNUAL REPORT | 2017-01-09 |
| ANNUAL REPORT | 2016-02-09 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
