| Entity Name: | COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 09 Nov 2015 (9 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 18 Oct 2016 (8 years ago) |
| Document Number: | L15000194049 |
| FEI/EIN Number | 81-4937645 |
| Address: | 279 SW MAIN BLVD, LAKE CITY, FL 32025 |
| Mail Address: | 279 SW MAIN BLVD, LAKE CITY, FL 32025 |
| ZIP code: | 32025 |
| County: | Columbia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1467652578 | 2007-07-18 | 2017-03-24 | 279 SW MAIN BLVD, LAKE CITY, FL, 320257050, US | 279 SW MAIN BLVD, LAKE CITY, FL, 320257050, US | |||||||||||||||||||||||||||||||
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| Phone | +1 386-752-4313 |
| Fax | 3867528356 |
Authorized person
| Name | DR. DARREL THOMAS MATHIS |
| Role | OWNER/PHYSICIAN |
| Phone | 3867524313 |
Taxonomy
| Taxonomy Code | 111NX0800X - Orthopedic Chiropractor |
| License Number | CH5141 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 050782200 |
| State | FL |
| Issuer | RAILROAD MEDICARE GROUP # |
| Number | CL2214 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| NORRIS, GUY W | Agent | 253 NW MAIN BLVD, LAKE CITY, FL 32055 |
| Name | Role | Address |
|---|---|---|
| DARREL T. MATHIS, D.C., D.A.C.O. | Authorized Representative | 279 SW MAIN BLVD, LAKE CITY, FL 32025 |
| MATHIS, MARY KAY | Authorized Representative | 179 NW OTTER COURT, LAKE CITY, FL 32055 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G18000136859 | COLUMBIA COUNTY CHIROPRACTIC CENTER, LLC | EXPIRED | 2018-12-28 | 2023-12-31 | No data | 279 SW MAIN BLVD, LAKE CITY, FL, 32025 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2016-10-18 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-17 |
| ANNUAL REPORT | 2024-01-08 |
| ANNUAL REPORT | 2023-01-20 |
| ANNUAL REPORT | 2022-01-05 |
| ANNUAL REPORT | 2021-01-11 |
| ANNUAL REPORT | 2020-02-21 |
| ANNUAL REPORT | 2019-01-18 |
| ANNUAL REPORT | 2018-01-17 |
| ANNUAL REPORT | 2017-02-24 |
| Reinstatement | 2016-10-18 |
Date of last update: 20 Jan 2025
Sources: Florida Department of State
