| Entity Name: | EARLY INTERVENTION SPECIALISTS OF NORTHWEST FLORIDA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 07 Mar 2013 (12 years ago) |
| Date of dissolution: | 25 Sep 2015 (9 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2015 (9 years ago) |
| Document Number: | L13000034848 |
| FEI/EIN Number | 46-2214164 |
| Address: | 5170 12TH AVE, MALONE, FL, 32445 |
| Mail Address: | 5170 12TH AVE, MALONE, FL, 32445 |
| ZIP code: | 32445 |
| County: | Jackson |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1063753572 | 2013-03-07 | 2013-03-07 | 5170 12TH AVE, MALONE, FL, 324453426, US | 5170 12TH AVE, MALONE, FL, 324453426, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 850-209-5880 |
| Fax | 8665214620 |
Authorized person
| Name | MARCIA S THOMPSON |
| Role | OWNER |
| Phone | 8502095880 |
Taxonomy
| Taxonomy Code | 252Y00000X - Early Intervention Provider Agency |
| License Number | RN3076242 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 810941900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| THOMPSON MARCIA S | Agent | 5170 12TH AVE, MALONE, FL, 32445 |
| Name | Role | Address |
|---|---|---|
| THOMPSON MARCIA S | Managing Member | 5170 12TH AVE, MALONE, FL, 32445 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2025-12-01 | 5170 12TH AVE, MALONE, FL 32445 | No data |
| CHANGE OF MAILING ADDRESS | 2025-12-01 | 5170 12TH AVE, MALONE, FL 32445 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2024-12-01 | 5170 12TH AVE, MALONE, FL 32445 | No data |
| CHANGE OF MAILING ADDRESS | 2024-12-01 | 5170 12TH AVE, MALONE, FL 32445 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2014-01-11 |
| Florida Limited Liability | 2013-03-07 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
