| Entity Name: | BREVARD PHYSICAL MEDICINE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 23 Jan 2015 (10 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 24 Oct 2016 (8 years ago) |
| Document Number: | L15000014324 |
| FEI/EIN Number | 59-3742631 |
| Mail Address: | 1715 Berglund Lane, #104, Melbourne, FL, 32940, US |
| Address: | 1715 Berglund Lane, Melbourne, FL, 32940, US |
| ZIP code: | 32940 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1548680531 | 2014-04-17 | 2015-04-29 | 6420 3RD STREET, SUITE 103, ROCKLEDGE, FL, 32955, US | 6420 3RD STREET, SUITE 103, ROCKLEDGE, FL, 32955, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 321-751-5351 |
| Fax | 3217515370 |
Authorized person
| Name | JOHN CHARLES MADLENER |
| Role | MEDICAL DOCTOR |
| Phone | 3217515351 |
Taxonomy
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| License Number | ME86688 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 225100000X - Physical Therapist |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 363A00000X - Physician Assistant |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 267338000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| HELTON DEENA M | Agent | 1715 Berglund Lane, Melbourne, FL, 32940 |
| Name | Role | Address |
|---|---|---|
| HELTON RICHARD D | Manager | 1692 QUINN DRIVE, ROCKLEDGE, FL, 32955 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2022-01-28 | 1715 Berglund Lane, #104, Melbourne, FL 32940 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-01-28 | 1715 Berglund Lane, #104, Melbourne, FL 32940 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-04-20 | 1715 Berglund Lane, #104, Melbourne, FL 32940 | No data |
| REINSTATEMENT | 2016-10-24 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-10-24 | HELTON, DEENA M | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-22 |
| ANNUAL REPORT | 2023-07-12 |
| ANNUAL REPORT | 2022-01-28 |
| ANNUAL REPORT | 2021-04-20 |
| ANNUAL REPORT | 2020-02-07 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-01-17 |
| ANNUAL REPORT | 2017-04-07 |
| REINSTATEMENT | 2016-10-24 |
| Florida Limited Liability | 2015-01-23 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
