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SPACE COAST MEDICAL, LLC

Company Details

Entity Name: SPACE COAST MEDICAL, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 01 Aug 2011 (14 years ago)
Last Event: LC AMENDMENT
Event Date Filed: 27 Mar 2024 (a year ago)
Document Number: L11000088035
FEI/EIN Number 453716351
Address: 2069 MOBILAND DR., MELBOURNE, FL, 32935, US
Mail Address: 2069 MOBILAND DR., MELBOURNE, FL, 32935, US
ZIP code: 32935
County: Brevard
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1376807511 2012-07-03 2015-07-28 4295 N US HIGHWAY 1, MELBOURNE, FL, 329354822, US 935 BAREFOOT BLVD, BLDG 1 SUITE 2, BAREFOOT BAY, FL, 329767620, US

Contacts

Phone +1 321-557-4667

Authorized person

Name JASON LAIL
Role C.E.O.
Phone 3215574667

Taxonomy

Taxonomy Code 208D00000X - General Practice Physician
License Number OS6898
State FL
Is Primary No
Taxonomy Code 261QP2000X - Physical Therapy Clinic/Center
Is Primary No
Taxonomy Code 261QR0400X - Rehabilitation Clinic/Center
Is Primary Yes

Agent

Name Role Address
YANCEY GINA Agent 2069 MOBILAND DR., MELBOURNE, FL, 32935

Manager

Name Role Address
LAIL JASON Manager 2069 MOBILAND DR., MELBOURNE, FL, 32935
YANCEY GINA L Manager 585 ORANGE GROVE AVE., MELBOURNE, FL, 32904

Officer

Name Role Address
YANCEY GINA L Officer 585 ORANGE GROVE AVE., MELBOURNE, FL, 32904

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G17000009132 SPACE COAST MEDICAL CONSULTING EXPIRED 2017-01-25 2022-12-31 No data 4295 N. US HWY 1, MELBOURNE, FL, 32935

Events

Event Type Filed Date Value Description
REGISTERED AGENT ADDRESS CHANGED 2024-03-27 2069 MOBILAND DR., MELBOURNE, FL 32935 No data
LC AMENDMENT 2024-03-27 No data No data
REGISTERED AGENT NAME CHANGED 2024-03-27 YANCEY, GINA No data
LC AMENDMENT 2024-03-19 No data No data
CHANGE OF PRINCIPAL ADDRESS 2024-03-19 2069 MOBILAND DR., MELBOURNE, FL 32935 No data
CHANGE OF MAILING ADDRESS 2024-03-19 2069 MOBILAND DR., MELBOURNE, FL 32935 No data
LC AMENDMENT 2022-12-22 No data No data
REINSTATEMENT 2015-09-28 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2015-09-25 No data No data

Documents

Name Date
LC Amendment 2024-03-27
LC Amendment 2024-03-19
ANNUAL REPORT 2024-02-29
ANNUAL REPORT 2023-02-27
LC Amendment 2022-12-22
ANNUAL REPORT 2022-04-20
ANNUAL REPORT 2021-01-15
ANNUAL REPORT 2020-03-03
ANNUAL REPORT 2019-01-17
ANNUAL REPORT 2018-03-05

Date of last update: 02 Feb 2025

Sources: Florida Department of State