| Entity Name: | CONVIVA SPECIALTY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 06 Jun 2016 (9 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 03 Aug 2022 (2 years ago) |
| Document Number: | L16000108766 |
| FEI/EIN Number | 81-2957926 |
| Address: | 500 West Main Street, Louisville, KY 40202 |
| Mail Address: | 500 West Main Street, Louisville, KY 40202 |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1326498676 | 2016-06-17 | 2024-06-21 | 6101 BLUE LAGOON DR STE 200, MIAMI, FL, 331263168, US | 12905 SW 42ND ST STE 103, MIAMI, FL, 331752910, US | |||||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 305-500-2000 |
| Phone | +1 786-801-5620 |
Authorized person
| Name | DR. EVAN JACOBS |
| Role | ASSOCIATE VP |
| Phone | 3055002000 |
Taxonomy
| Taxonomy Code | 207RC0000X - Cardiovascular Disease Physician |
| Is Primary | Yes |
| Taxonomy Code | 207RG0100X - Gastroenterology Physician |
| Is Primary | No |
| Taxonomy Code | 207T00000X - Neurological Surgery Physician |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | ME116882 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| License Number | ME129977 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 021709600 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CT CORPORATION SYSTEM | Agent | 1200 S PINE ISLAND RD, PLANTATION, FL 33324 |
| Name | Role | Address |
|---|---|---|
| Diamond, Susan Marie | Chief Financial Officer | 500 West Main Street, Louisville, KY 40202 |
| Lindsay-Jones, Richard | Chief Financial Officer | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Edwards, Douglas Allen | Senior Vice President | 500 West Main Street, Louisville, KY 40202 |
| Meriwether, Kevin | Senior Vice President | 500 West Main Street, Louisville, KY 40202 |
| Garg, Vivek, M.D. | Senior Vice President | 500 West Main Street, Louisville, KY 40202 |
| Greenfield-LaTour, Cheri | Senior Vice President | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Edwards, Douglas Allen | Enterprise Associate | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Edwards, Douglas Allen | Business Solutions | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Feld, Daniel Kevin | Associate VP | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Feld, Daniel Kevin | Tax | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Marcoux, Robert Martin, Jr. | Vice President and Treasurer | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Buckingham, Renee Jacqueline | President | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Pabo, Erika | Vice President | 500 West Main Street, Louisville, KY 40202 |
| Morrell, Joshua | Vice President | 500 West Main Street, Louisville, KY 40202 |
| Adkins, Matt | Vice President | 500 West Main Street, Louisville, KY 40202 |
| Lindsay-Jones, Richard | Vice President | 500 West Main Street, Louisville, KY 40202 |
| Ruschell, Joseph Matthew | Vice President | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Pabo, Erika | Primary Care Transformation | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Morrell, Joshua | Population Health Analytics and Utilization Management Services | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Meriwether, Kevin | Division President | 500 West Main Street, Louisville, KY 40202 |
| Greenfield-LaTour, Cheri | Division President | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Meriwether, Kevin | Care Delivery | 500 West Main Street, Louisville, KY 40202 |
| Garg, Vivek, M.D. | Care Delivery | 500 West Main Street, Louisville, KY 40202 |
| Greenfield-LaTour, Cheri | Care Delivery | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Buckingham, Renee Jacqueline | Manager | 500 West Main Street, Louisville, KY 40202 |
| Ruschell, Joseph Matthew | Manager | 500 West Main Street, Louisville, KY 40202 |
| Diamond, Susan Marie | Manager | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Adkins, Matt | Integration | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Adkins, Matt | Transformation | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Garg, Vivek, M.D. | Chief Medical Officer | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Lindsay-Jones, Richard | Primary Care Organization | 500 West Main Street, Louisville, KY 40202 |
| Name | Role | Address |
|---|---|---|
| Ruschell, Joseph Matthew | Associate General Counsel and Corporate Secretary | 500 West Main Street, Louisville, KY 40202 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000095846 | CONVIVA SENIOR PRIMARY CARE | ACTIVE | 2024-08-12 | 2029-12-31 | No data | 500 WEST MAIN STREET, LOUISVILLE, KY, 40202 |
| G24000095847 | CONVIVA SENIOR PRIMARY CARE, A CENTERWELL COMPANY | ACTIVE | 2024-08-12 | 2029-12-31 | No data | 500 WEST MAIN STREET, LOUISVILLE, KY, 40202 |
| G23000090580 | CONVIVA PRIMARY CARE ANYWHERE | ACTIVE | 2023-08-03 | 2028-12-31 | No data | 500 WEST MAIN STREET, LOUISEVILLE, KY, 40202, CO |
| G20000118289 | CONVIVA CARE CENTER | ACTIVE | 2020-09-10 | 2025-12-31 | No data | 500 WEST MAIN STREET, LOUISVILLE, KY, 40202 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-03-11 | 500 West Main Street, Louisville, KY 40202 | No data |
| CHANGE OF MAILING ADDRESS | 2024-03-11 | 500 West Main Street, Louisville, KY 40202 | No data |
| LC STMNT OF RA/RO CHG | 2022-08-03 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-08-03 | 1200 S PINE ISLAND RD, PLANTATION, FL 33324 | No data |
| REGISTERED AGENT NAME CHANGED | 2022-08-03 | CT CORPORATION SYSTEM | No data |
| MERGER | 2020-10-01 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. MERGER NUMBER 900000206209 |
| LC AMENDMENT AND NAME CHANGE | 2020-08-18 | CONVIVA SPECIALTY, LLC | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-09-16 |
| ANNUAL REPORT | 2024-03-11 |
| ANNUAL REPORT | 2023-04-29 |
| CORLCRACHG | 2022-08-03 |
| ANNUAL REPORT | 2022-04-19 |
| AMENDED ANNUAL REPORT | 2021-10-19 |
| ANNUAL REPORT | 2021-04-29 |
| Merger | 2020-10-01 |
| AMENDED ANNUAL REPORT | 2020-08-28 |
| LC Amendment and Name Change | 2020-08-18 |
Date of last update: 20 Jan 2025
Sources: Florida Department of State
