| Entity Name: | KGC CRNA LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 12 Jun 2013 (12 years ago) |
| Document Number: | L13000085174 |
| FEI/EIN Number | 462977173 |
| Address: | 3337 CAPPIO DRIVE, MELBOURNE, FL, 32940 |
| Mail Address: | 3337 Cappio Drive, MELBOURNE, FL, 32940-1313, US |
| ZIP code: | 32940 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1609215730 | 2013-06-21 | 2013-07-19 | PO BOX 410580, MELBOURNE, FL, 329410580, US | 3337 CAPPIO DR, MELBOURNE, FL, 329401313, US | |||||||||||||||||||||||
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| Phone | +1 321-759-4460 |
Authorized person
| Name | KANDEE GEORGETTE COPPALA |
| Role | MANAGER/OWNER |
| Phone | 3217594460 |
Taxonomy
| Taxonomy Code | 367500000X - Certified Registered Nurse Anesthetist |
| License Number | ARNP 9217913 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 306690800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| COPPALA KANDEE G | Agent | 3337 CAPPIO DRIVE, MELBOURNE, FL, 32940 |
| Name | Role | Address |
|---|---|---|
| COPPALA KANDEE G | Manager | 3337 CAPPIO DRIVE, MELBOURNE, FL, 32940 |
| Name | Role | Address |
|---|---|---|
| Coppala Eric M | Firs | 3337 CAPPIO DRIVE, MELBOURNE, FL, 32940 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2022-01-30 | 3337 CAPPIO DRIVE, MELBOURNE, FL 32940 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-16 |
| ANNUAL REPORT | 2024-02-01 |
| ANNUAL REPORT | 2023-02-03 |
| ANNUAL REPORT | 2022-01-30 |
| ANNUAL REPORT | 2021-02-09 |
| ANNUAL REPORT | 2020-02-24 |
| ANNUAL REPORT | 2019-02-21 |
| ANNUAL REPORT | 2018-01-22 |
| ANNUAL REPORT | 2017-01-21 |
| ANNUAL REPORT | 2016-03-28 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
