| Entity Name: | ELLENTON FAMILY PRACTICE DIRECT PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 Jan 2016 (9 years ago) |
| Document Number: | L16000001454 |
| FEI/EIN Number | 811042237 |
| Address: | 907 25TH DRIVE EAST, ELLENTON, FL, 34222, US |
| Mail Address: | 1005 Meadow Breeze Lane, sarasota, FL, 34240, US |
| ZIP code: | 34222 |
| County: | Manatee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124471503 | 2016-07-20 | 2023-03-07 | 907 25TH DR E, ELLENTON, FL, 342222053, US | 907 25TH DR E, ELLENTON, FL, 342222053, US | |||||||||||||||||||||||||
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| Phone | +1 941-417-7386 |
| Phone | +1 941-321-8299 |
Authorized person
| Name | MR. DAVID ALLAN HERVIG |
| Role | OFFICE MANAGE AND PARTNER |
| Phone | 9417305326 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | PA9102767 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | LICENSE |
| Number | OS12316 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ULRICH, SCARLETT, WICKMAN & DEAN, PA | Agent | 713 S. ORANGE AVENUE, SARASOTA, FL, 34236 |
| Name | Role | Address |
|---|---|---|
| Kulawik Raphael | Manager | 1005 Meadow Breeze Lane, sarasota, FL, 34240 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2023-08-30 | 907 25TH DRIVE EAST, ELLENTON, FL 34222 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-05-01 | 907 25TH DRIVE EAST, ELLENTON, FL 34222 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-30 |
| ANNUAL REPORT | 2023-08-30 |
| ANNUAL REPORT | 2022-05-11 |
| ANNUAL REPORT | 2021-04-26 |
| ANNUAL REPORT | 2020-04-22 |
| ANNUAL REPORT | 2019-09-02 |
| ANNUAL REPORT | 2018-05-01 |
| ANNUAL REPORT | 2017-04-28 |
| Florida Limited Liability | 2016-01-05 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 7875087306 | 2020-04-30 | 0455 | PPP | 907 25th Drive East, Ellenton, FL, 34222-2053 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 01 Feb 2025
Sources: Florida Department of State
