| Entity Name: | FOOT FIRST PODIATRY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 27 Dec 2012 (12 years ago) |
| Date of dissolution: | 22 Sep 2017 (7 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 22 Sep 2017 (7 years ago) |
| Document Number: | L12000160690 |
| FEI/EIN Number | 46-1664214 |
| Address: | 303 southlake ct, Niceville, FL, 32578, US |
| Mail Address: | PO Box 1199, DeFuniak Springs, FL, 32435, US |
| ZIP code: | 32578 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1053658963 | 2013-01-11 | 2013-01-11 | PO BOX 1199, DEFUNIAK SPRINGS, FL, 324351199, US | 2600 HOSPITAL DR, BONIFAY, FL, 324254264, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 407-443-9784 |
| Fax | 8505478090 |
| Phone | +1 850-547-8117 |
Authorized person
| Name | DR. KELVIN DEVANE GIPSON |
| Role | OWNER |
| Phone | 4074439784 |
Taxonomy
| Taxonomy Code | 213ES0103X - Foot & Ankle Surgery Podiatrist |
| License Number | PO 2195 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 002040200 |
| State | FL |
| Issuer | MEDICARE PART B |
| Number | CZ576A |
| State | FL |
| Name | Role | Address |
|---|---|---|
| GIPSON KELVIN D | Agent | 303 southlake ct, Niceville, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| GIPSON KELVIN D | Manager | 303 southlake ct, Niceville, FL, 32578 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2015-01-09 | 303 southlake ct, Niceville, FL 32578 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-01-09 | 303 southlake ct, Niceville, FL 32578 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-20 | 303 southlake ct, Niceville, FL 32578 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2016-01-28 |
| ANNUAL REPORT | 2015-01-09 |
| ANNUAL REPORT | 2014-01-20 |
| ANNUAL REPORT | 2013-04-17 |
| Florida Limited Liability | 2012-12-27 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
