| Entity Name: | PEDIATRICS & FAMILY MEDICINE OF BUENA VISTA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 12 Aug 2013 (12 years ago) |
| Document Number: | L13000113310 |
| FEI/EIN Number | 46-3504736 |
| Address: | 519 BUENA VISTA STREET, LAKELAND, FL, 33809, US |
| Mail Address: | 519 BUENA VISTA STREET, LAKELAND, FL, 33809, US |
| ZIP code: | 33809 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1053747188 | 2013-09-20 | 2013-09-20 | 519 BUENA VISTA ST, LAKELAND, FL, 338054504, US | 10552 NW 13TH AVE, GAINESVILLE, FL, 326068088, US | |||||||||||||||||||||||
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| Phone | +1 678-570-5063 |
Authorized person
| Name | BILAL KHODR |
| Role | MEDICAL DIRECTOR |
| Phone | 3522131243 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| License Number | ME0072652 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 252009500 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Simon Mulinda P | Agent | 519 BUENA VISTA STREET, LAKELAND, FL, 33809 |
| Name | Role | Address |
|---|---|---|
| MULINDA SIMON P | Manager | 519 BUENA VISTA STREET, LAKELAND, FL, 33809 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2014-04-23 | Simon, Mulinda P | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-04-23 | 519 BUENA VISTA STREET, LAKELAND, FL 33809 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-15 |
| ANNUAL REPORT | 2023-01-24 |
| ANNUAL REPORT | 2022-03-14 |
| ANNUAL REPORT | 2021-02-25 |
| ANNUAL REPORT | 2020-04-27 |
| ANNUAL REPORT | 2019-04-09 |
| ANNUAL REPORT | 2018-03-29 |
| ANNUAL REPORT | 2017-04-06 |
| ANNUAL REPORT | 2016-04-21 |
| ANNUAL REPORT | 2015-04-21 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
