| Entity Name: | THE INSTITUTE FOR HEALTH, SPORTS, SPINE REHABILITATION & PAIN MANAGEMENT, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 01 Sep 2015 (9 years ago) |
| Document Number: | L15000147053 |
| FEI/EIN Number | 47-4966216 |
| Address: | 1895 KINGSLEY AVE, ORANGE PARK, FL, 32073, US |
| Mail Address: | 1895 KINGSLEY AVE, ORANGE PARK, FL, 32073, US |
| ZIP code: | 32073 |
| County: | Clay |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245802727 | 2021-07-14 | 2021-07-14 | 111 MARGARET ST, SAINT MARYS, GA, 315584930, US | 4100 SOUTHPOINT DR E STE 1, JACKSONVILLE, FL, 322168710, US | |||||||||||||||||||||
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| Phone | +1 904-647-5266 |
| Fax | 9047705594 |
Authorized person
| Name | SHANNON RILEY |
| Role | VP OF OPERATIONS |
| Phone | 9046475266 |
Taxonomy
| Taxonomy Code | 2081P2900X - Pain Medicine (Physical Medicine & Rehabilitation) Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 014945000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| RILEY SHANNON | Agent | 1895 KINGSLEY AVE, ORANGE PARK, FL, 32073 |
| Name | Role | Address |
|---|---|---|
| von Tobel Travis | Member | 1895 Kingsley Ave, Orange Park, FL, 32073 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000093392 | THE INSTITUTE FOR FLORIDA PAIN SPECIALISTS | ACTIVE | 2021-07-16 | 2026-12-31 | No data | 1604 MARARET STREET, JACKSONVILLE, FL, 32204 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-02-12 | 1895 KINGSLEY AVE, 1005B, ORANGE PARK, FL 32073 | No data |
| CHANGE OF MAILING ADDRESS | 2024-02-12 | 1895 KINGSLEY AVE, 1005B, ORANGE PARK, FL 32073 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-02-12 | 1895 KINGSLEY AVE, 1005B, ORANGE PARK, FL 32073 | No data |
| REGISTERED AGENT NAME CHANGED | 2019-02-22 | RILEY, SHANNON | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J18000723262 | TERMINATED | 1000000800130 | CLAY | 2018-10-18 | 2028-10-31 | $ 142.78 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-12 |
| ANNUAL REPORT | 2023-02-06 |
| ANNUAL REPORT | 2022-03-16 |
| ANNUAL REPORT | 2021-01-06 |
| ANNUAL REPORT | 2020-03-02 |
| ANNUAL REPORT | 2019-02-22 |
| ANNUAL REPORT | 2018-05-01 |
| ANNUAL REPORT | 2017-05-01 |
| ANNUAL REPORT | 2016-09-15 |
| Florida Limited Liability | 2015-09-01 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
