| Entity Name: | LAKEMONT PEDIATRICS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 22 Dec 2014 (10 years ago) |
| Document Number: | L14000194079 |
| FEI/EIN Number | 47-2576011 |
| Address: | 157 NORTH LAKEMONT AVE, WINTER PARK, FL, 32792 |
| Mail Address: | 157 NORTH LAKEMONT AVE, WINTER PARK, FL, 32792 |
| ZIP code: | 32792 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1053793190 | 2015-06-25 | 2015-06-25 | 157 N LAKEMONT AVE, WINTER PARK, FL, 327923214, US | 157 N LAKEMONT AVE, WINTER PARK, FL, 327923214, US | |||||||||||||||||||||||||
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| Phone | +1 407-644-6618 |
| Fax | 4076443755 |
Authorized person
| Name | DR. VIVIEN D PHAM |
| Role | MANAGER/PHYSICIAN |
| Phone | 4076446618 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME100800 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 281279700 |
| State | FL |
| Name | Role |
|---|---|
| LAKEMONT PEDIATRICS, LLC | Agent |
| Name | Role | Address |
|---|---|---|
| Pham Vivien D | Manager | 157 NORTH LAKEMONT AVE, WINTER PARK, FL, 32792 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G15000004230 | LAKEMONT PEDIATRICS | ACTIVE | 2015-01-13 | 2025-12-31 | No data | 157 N LAKEMONT AVE., WINTER PARK, FL, 32792 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2018-02-19 | LAKEMONT PEDIATRICS | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-02-19 | 157 N LAKEMONT AVE., WINTER PARK, FL 32792 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-01-31 |
| ANNUAL REPORT | 2022-01-27 |
| ANNUAL REPORT | 2021-03-15 |
| ANNUAL REPORT | 2020-03-27 |
| ANNUAL REPORT | 2019-02-07 |
| ANNUAL REPORT | 2018-02-19 |
| ANNUAL REPORT | 2017-01-10 |
| ANNUAL REPORT | 2016-01-28 |
| ANNUAL REPORT | 2015-01-23 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
