| Entity Name: | PRINCIPLE MEDICAL GROUP, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 16 Feb 2010 (15 years ago) |
| Document Number: | L10000017464 |
| FEI/EIN Number | 271915515 |
| Address: | 4000 Highway 90, Pace, FL, 32571, US |
| Mail Address: | 4000 Highway 90, Pace, FL, 32571, US |
| ZIP code: | 32571 |
| County: | Santa Rosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407179989 | 2010-03-11 | 2013-02-13 | 7000 COBBLE CRK, PENSACOLA, FL, 325048638, US | 7000 COBBLE CRK, PENSACOLA, FL, 325048638, US | |||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 850-776-4265 |
Authorized person
| Name | DR. ROMAN S. BAUTISTA |
| Role | PRESIDENT |
| Phone | 8507764265 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | OS7158 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 265911500 |
| State | FL |
| Issuer | MEDICAID |
| Number | 009913418 |
| State | AL |
| Issuer | BC/BS OF ALABAMA |
| Number | 59067672 |
| State | AL |
| Issuer | BCBS OF FLORIDA |
| Number | 62842 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BAUTISTA ROMAN S | Agent | 4000 Highway 90, Pace, FL, 32571 |
| Name | Role | Address |
|---|---|---|
| BAUTISTA ROMAN S | Managing Member | 3978 GORDON WELLS DRIVE, MILTON, FL, 32583 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G17000035512 | QUICKSTART MEDICAL WEIGHT LOSS CLINIC | EXPIRED | 2017-04-04 | 2022-12-31 | No data | 4106 GULF BREEZE PKWY, GULF BREEZE, FL, 32563 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-04-29 | 4000 Highway 90, Suite I, Pace, FL 32571 | No data |
| CHANGE OF MAILING ADDRESS | 2022-04-29 | 4000 Highway 90, Suite I, Pace, FL 32571 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-04-29 | 4000 Highway 90, Suite I, Pace, FL 32571 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-05-01 |
| ANNUAL REPORT | 2023-02-24 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-02-26 |
| ANNUAL REPORT | 2020-03-05 |
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-03-16 |
| ANNUAL REPORT | 2017-02-21 |
| ANNUAL REPORT | 2016-03-08 |
| ANNUAL REPORT | 2015-03-02 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
