| Entity Name: | BRIAN B. WALLS MD, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 08 Feb 2016 (9 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 06 Aug 2024 (6 months ago) |
| Document Number: | L16000026798 |
| FEI/EIN Number | 82-0806097 |
| Address: | 500 CROCKETT BLVD., MERRITT ISLAND, FL, 32953, US |
| Mail Address: | 500 CROCKETT BLVD., MERRITT ISLAND, FL, 32953, US |
| ZIP code: | 32953 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891165023 | 2015-09-30 | 2017-05-22 | PO BOX 540033, MERRITT ISLAND, FL, 329540033, US | 500 CROCKETT BLVD, MERRITT ISLAND, FL, 329535034, US | |||||||||||||||||||||||||||
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| Phone | +1 321-243-8593 |
| Fax | 3214542325 |
| Fax | 3214542523 |
Authorized person
| Name | DR. BRIAN B WALLS |
| Role | PHYSICIAN / OWNER |
| Phone | 3212438593 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | ME71812 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 251358700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| WALLS BRIAN B | Agent | 500 CROCKETT BLVD., MERRITT ISLAND, FL, 32953 |
| Name | Role | Address |
|---|---|---|
| WALLS BRIAN B | Authorized Member | 500 CROCKETT BLVD., MERRITT ISLAND, FL, 32953 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-08-06 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| REINSTATEMENT | 2019-06-04 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2019-06-04 | WALLS, BRIAN B | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-08-06 |
| REINSTATEMENT | 2019-06-04 |
| Florida Limited Liability | 2016-02-08 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
