| Entity Name: | EMERALD COAST DIABETES & NUTRITION CENTER LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 20 Jun 2017 (8 years ago) |
| Document Number: | L17000134217 |
| FEI/EIN Number | 82-1913367 |
| Address: | 115 Miracle Strip Pkwy SE, Suite 101, Fort Walton Beach, FL, 32548, US |
| Mail Address: | 115 Miracle Strip Pkwy SE, Suite 101, Fort Walton Beach, FL, 32548, US |
| ZIP code: | 32548 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1700307550 | 2017-07-02 | 2022-09-13 | 115 MIRACLE STRIP PKWY SE UNIT 101, FORT WALTON BEACH, FL, 325485976, US | 115 MIRACLE STRIP PKWY SE UNIT 101, FORT WALTON BEACH, FL, 325485976, US | |||||||||||||||||||||||||||||||||||
|
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| Phone | +1 850-374-7604 |
| Fax | 8507922545 |
Authorized person
| Name | DEANNA HOWARD-GONZALEZ |
| Role | OWNER |
| Phone | 8503747604 |
Taxonomy
| Taxonomy Code | 133V00000X - Registered Dietitian |
| License Number | ND3885 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 208D00000X - General Practice Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 1J0TM |
| State | FL |
| Issuer | FLORIDA LICENSE |
| Number | ND3885 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| HOWARD-GONZALEZ DEANNA M | Agent | 290 BRIAN CIRCLE, MARY ESTHER, FL, 32569 |
| Name | Role | Address |
|---|---|---|
| HOWARD-GONZALEZ DEANNA | Manager | 290 BRIAN CIRCLE, MARY ESTHER, FL, 32569 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-01-27 | 115 Miracle Strip Pkwy SE, Suite 101, Fort Walton Beach, FL 32548 | No data |
| CHANGE OF MAILING ADDRESS | 2023-01-27 | 115 Miracle Strip Pkwy SE, Suite 101, Fort Walton Beach, FL 32548 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-01 |
| ANNUAL REPORT | 2023-01-27 |
| ANNUAL REPORT | 2022-04-06 |
| ANNUAL REPORT | 2021-02-22 |
| ANNUAL REPORT | 2020-03-18 |
| ANNUAL REPORT | 2019-04-04 |
| ANNUAL REPORT | 2018-03-04 |
| Florida Limited Liability | 2017-06-20 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
