| Entity Name: | INNOVATIVE PHYSIATRY SPINE CLINIC, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 06 Jun 2017 (8 years ago) |
| Document Number: | L17000123417 |
| FEI/EIN Number | 82-1817146 |
| Address: | 165 Durbin Station Ct, St. Johns, FL, 32259, US |
| Mail Address: | P O BOX 385, PONTE VEDRA BEACH, FL, 32004, US |
| ZIP code: | 32259 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1487175881 | 2017-07-06 | 2021-09-02 | PO BOX 385, PONTE VEDRA BEACH, FL, 320040385, US | 165 DURBIN STATION CT STE 601, ST JOHNS, FL, 322599370, US | |||||||||||||||||||
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| Phone | +1 904-671-0288 |
| Fax | 9045080674 |
Authorized person
| Name | SECK LIM |
| Role | PRACTICE ADMINISTRATOR |
| Phone | 9046710288 |
Taxonomy
| Taxonomy Code | 2081P2900X - Pain Medicine (Physical Medicine & Rehabilitation) Physician |
| License Number | OS12124 |
| State | FL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| LEE SUYIN J | Agent | 165 Durbin Station Ct, St. Johns, FL, 32259 |
| Name | Role | Address |
|---|---|---|
| LEE SUYIN J | Chief Executive Officer | P O BOX 385, PONTE VEDRA BEACH, FL, 32004 |
| Name | Role | Address |
|---|---|---|
| LIM SECK S | Chief Operating Officer | P O BOX 385, PONTE VEDRA BEACH, FL, 32004 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2021-01-30 | 165 Durbin Station Ct, Suite 601, St. Johns, FL 32259 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-01-30 | 165 Durbin Station Ct, Suite 601, St. Johns, FL 32259 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-24 |
| ANNUAL REPORT | 2023-01-18 |
| ANNUAL REPORT | 2022-01-24 |
| ANNUAL REPORT | 2021-01-30 |
| ANNUAL REPORT | 2020-03-20 |
| ANNUAL REPORT | 2019-04-01 |
| ANNUAL REPORT | 2018-01-14 |
| Florida Limited Liability | 2017-06-06 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
