| Entity Name: | FORT MYERS FAMILY MEDICINE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 27 Jun 2011 (14 years ago) |
| Date of dissolution: | 30 Apr 2019 (6 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 30 Apr 2019 (6 years ago) |
| Document Number: | L11000074767 |
| FEI/EIN Number | 650938486 |
| Address: | 15661 SAN CARLOS BLVD., SUITE 2, FORT MYERS, FL, 33908 |
| Mail Address: | 15661 SAN CARLOS BLVD., SUITE 2, FORT MYERS, FL, 33908 |
| ZIP code: | 33908 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1255436143 | 2006-09-14 | 2018-06-20 | 15661 SAN CARLOS BLVD, SUITE 2, FORT MYERS, FL, 339082797, US | 15661 SAN CARLOS BLVD, SUITE 2, FORT MYERS, FL, 33908, US | |||||||||||||||||||||||||||||||
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| Phone | +1 239-433-4014 |
| Fax | 2394816247 |
Authorized person
| Name | DR. HURSEL LEE ADKINS JR. |
| Role | EXECUTIVE MANAGING DIRECTOR |
| Phone | 2394334014 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | OS0005720 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 268237100 |
| State | FL |
| Issuer | MEDICARE PTAN |
| Number | K1484 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KYLE KEVIN A | Agent | 1380 ROYAL PALM SQUARE BLVD., FORT MYERS, FL, 33919 |
| Name | Role | Address |
|---|---|---|
| ADKINS H. LEE | Manager | 15661 SAN CARLOS BLVD., SUITE 2, FORT MYERS, FL, 33908 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2019-04-30 | No data | No data |
| CONVERSION | 2011-06-27 | No data | CORPORATION WAS A CONVERSION RESULT. CONVERTING CORPORATION WAS P99000066407. CONVERSION NUMBER 100000114711 |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2019-04-30 |
| ANNUAL REPORT | 2018-06-26 |
| ANNUAL REPORT | 2017-04-27 |
| ANNUAL REPORT | 2016-04-29 |
| ANNUAL REPORT | 2015-04-28 |
| ANNUAL REPORT | 2014-03-13 |
| ANNUAL REPORT | 2013-04-16 |
| ANNUAL REPORT | 2012-01-04 |
| Florida Limited Liability | 2011-06-27 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
