| Entity Name: | BREVARD GERIATRICS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 14 May 2014 (11 years ago) |
| Document Number: | L14000078730 |
| FEI/EIN Number | 465713553 |
| Address: | 720 E. NEW HAVEN AVENUE, SUITE 11, MELBOURNE, FL, 32901, US |
| Mail Address: | 720 E. NEW HAVEN AVENUE, SUITE 11, MELBOURNE, FL, 32901, US |
| ZIP code: | 32901 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225682784 | 2019-08-01 | 2019-08-01 | 720 E NEW HAVEN AVE SUITE 11, MELBOURNE, FL, 329015474, US | 720 E NEW HAVEN AVE SUITE 11, MELBOURNE, FL, 329015474, US | |||||||||||||||||||||
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| Phone | +1 321-724-4545 |
| Fax | 3217284168 |
Authorized person
| Name | JOHN POTOMSKI |
| Role | OWNER |
| Phone | 3214465893 |
Taxonomy
| Taxonomy Code | 207QG0300X - Geriatric Medicine (Family Medicine) Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 067596200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ANDERSON J. PATRICK | Agent | 2200 FRONT STREET, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| JOHN H. POTOMASKI, JR., D.O. | Managing Member | 720 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| CLEGG SUSAN C | Manager | 720 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-03-06 |
| ANNUAL REPORT | 2022-02-14 |
| ANNUAL REPORT | 2021-01-30 |
| ANNUAL REPORT | 2020-02-13 |
| ANNUAL REPORT | 2019-04-26 |
| ANNUAL REPORT | 2018-04-22 |
| ANNUAL REPORT | 2017-04-22 |
| ANNUAL REPORT | 2016-01-30 |
| ANNUAL REPORT | 2015-04-26 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
