| Entity Name: | BENGSTON FAMILY PRACTICE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 01 Mar 2012 (13 years ago) |
| Date of dissolution: | 27 Sep 2013 (11 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2013 (11 years ago) |
| Document Number: | L12000029709 |
| Address: | 870 W. HICKPOCHEE AVE., SUITE 1700, LABELLE, FL, 33935, US |
| Mail Address: | 870 W. HICKPOCHEE AVE., SUITE 1700, LABELLE, FL, 33935, US |
| ZIP code: | 33935 |
| County: | Hendry |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003180381 | 2012-03-03 | 2012-03-07 | 870 W HICKPOCHEE AVE, SSUITE 1700, LABELLE, FL, 339354313, US | 870 W HICKPOCHEE AVE, SSUITE 1700, LABELLE, FL, 339354313, US | |||||||||||||||||||||||||
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| Phone | +1 863-675-0550 |
| Fax | 8636750553 |
Authorized person
| Name | EVELYN SUSANNE BENGSTON |
| Role | ARNP |
| Phone | 8636750550 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | ARNP2209102 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 302076200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BENGSTON EVELYN S | Agent | 870 W. HICKPOCHEE AVE., LABELLE, FL, 33935 |
| Name | Role | Address |
|---|---|---|
| BENGSTON EVELYN S | Managing Member | 870 W. HICKPOCHEE AVE. STE 1700, LABELLE, FL, 33935 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2013-09-27 | No data | No data |
| Name | Date |
|---|---|
| Florida Limited Liability | 2012-03-01 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
