| Entity Name: | CONVIVA SPECIALTY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: |
Florida Limited Liability Co.
CONVIVA SPECIALTY, LLC is structured as a Limited Liability Company (LLC), a common business structure that offers its members limited liability protection, separating their personal assets from the company's debts and obligations. |
| Status: |
Active
The business entity is active. This status indicates that the business is currently operating and compliant with state regulations, suggesting a lower risk profile for lenders and potentially better creditworthiness. |
| Date Filed: | 06 Jun 2016 (9 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 03 Aug 2022 (3 years ago) |
| Document Number: | L16000108766 |
| FEI/EIN Number |
81-2957926
Federal Employer Identification (FEI) Number assigned by the IRS. |
| Address: | 500 West Main Street, Louisville, KY, 40202, US |
| Mail Address: | 500 West Main Street, Louisville, KY, 40202, US |
| 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 |
|---|---|---|
| Diamond Susan M | Chief Financial Officer | 500 West Main Street, Louisville, KY, 40202 |
| Edwards Douglas A | Seni | 500 West Main Street, Louisville, KY, 40202 |
| Feld Daniel K | Asso | 500 West Main Street, Louisville, KY, 40202 |
| Marcoux Robert M | Vice President | 500 West Main Street, Louisville, KY, 40202 |
| Buckingham Renee J | President | 500 West Main Street, Louisville, KY, 40202 |
| Pabo Erika M | Vice President | 500 West Main Street, Louisville, KY, 40202 |
| CT CORPORATION SYSTEM | Agent | 1200 S PINE ISLAND RD, PLANTATION, FL, 33324 |
| 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 | - | 500 WEST MAIN STREET, LOUISVILLE, KY, 40202 |
| G24000095847 | CONVIVA SENIOR PRIMARY CARE, A CENTERWELL COMPANY | ACTIVE | 2024-08-12 | 2029-12-31 | - | 500 WEST MAIN STREET, LOUISVILLE, KY, 40202 |
| G23000090580 | CONVIVA PRIMARY CARE ANYWHERE | ACTIVE | 2023-08-03 | 2028-12-31 | - | 500 WEST MAIN STREET, LOUISEVILLE, KY, 40202, CO |
| G20000118289 | CONVIVA CARE CENTER | ACTIVE | 2020-09-10 | 2025-12-31 | - | 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 | - |
| CHANGE OF MAILING ADDRESS | 2024-03-11 | 500 West Main Street, Louisville, KY 40202 | - |
| LC STMNT OF RA/RO CHG | 2022-08-03 | - | - |
| REGISTERED AGENT ADDRESS CHANGED | 2022-08-03 | 1200 S PINE ISLAND RD, PLANTATION, FL 33324 | - |
| REGISTERED AGENT NAME CHANGED | 2022-08-03 | CT CORPORATION SYSTEM | - |
| MERGER | 2020-10-01 | - | 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 | - |
| 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: 02 Apr 2025
Sources: Florida Department of State
