| Entity Name: | PORTILLA MEDICAL GROUP,LLC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 17 Jun 2013 (12 years ago) |
| Date of dissolution: | 23 Sep 2016 (8 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 23 Sep 2016 (8 years ago) |
| Document Number: | L13000086586 |
| FEI/EIN Number | 46-2984867 |
| Address: | 330 SW 27TH AVE, 302, MIAMI, FL, 33135, US |
| Mail Address: | 330 SW 27TH AVE, 302, MIAMI, FL, 33135, US |
| ZIP code: | 33135 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124467717 | 2013-06-18 | 2014-09-11 | 330 SW 27TH AVE, STE 302, MIAMI, FL, 331352961, US | 330 SW 27TH AVE, STE 302, MIAMI, FL, 331352961, US | |||||||||||||||||||||||||||
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| Phone | +1 305-631-1220 |
| Fax | 3056311251 |
Authorized person
| Name | DR. MARIANELA DE LA PORTILLA |
| Role | PRESIDENT/MEDICAL DIRECTOR |
| Phone | 3056311220 |
Taxonomy
| Taxonomy Code | 261QM1300X - Multi-Specialty Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 010921800 |
| State | FL |
| Issuer | MEDICARE PTAN |
| Number | HU244A |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DE LA PORTILLA MARIANELA | Agent | 330 SW 27 AVE, MIAMI, FL, 33135 |
| Name | Role | Address |
|---|---|---|
| De la Portilla Marianela | Auth | 330 SW 27TH AVE, MIAMI, FL, 33135 |
| Name | Role | Address |
|---|---|---|
| DE LA PORTILLA ARIEL | Manager | 330 SW 27TH AVE, MIAMI, FL, 33135 |
| DE LA PORTILLA MANUEL | Manager | 330 SW 27TH AVE, MIAMI, FL, 33135 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G15000077108 | PORTILLA MEDICAL GROUP & RESEARCH | EXPIRED | 2015-07-24 | 2020-12-31 | No data | 330 SW 27TH AVE, SUITE 302, MIAMI, FL, 33135 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| LC AMENDMENT | 2016-05-16 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-05-16 | DE LA PORTILLA, MARIANELA | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-12-14 | 330 SW 27 AVE, 302, MIAMI, FL 33135 | No data |
| Name | Date |
|---|---|
| LC Amendment | 2016-05-16 |
| AMENDED ANNUAL REPORT | 2015-12-22 |
| AMENDED ANNUAL REPORT | 2015-12-16 |
| AMENDED ANNUAL REPORT | 2015-12-14 |
| ANNUAL REPORT | 2015-04-27 |
| ANNUAL REPORT | 2014-02-25 |
| Florida Limited Liability | 2013-06-17 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
