| Entity Name: | JACKSONVILLE LUNG CLINIC, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 08 Jan 2018 (7 years ago) |
| Last Event: | LC AMENDMENT AND NAME CHANGE |
| Event Date Filed: | 12 Apr 2018 (7 years ago) |
| Document Number: | L18000007181 |
| FEI/EIN Number | 82-3920888 |
| Address: | 2624 Atlantic Bouvelard, Jacksonville, FL, 32207, US |
| Mail Address: | 7500 Rialto Blvd., Bldg. 1, Austin, TX, 78735, US |
| ZIP code: | 32207 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1861991937 | 2018-02-05 | 2023-04-04 | 7500 RIALTO BLVD, AUSTIN, TX, 787358531, US | 1350 13TH AVE S, JACKSONVILLE BEACH, FL, 322503203, US | |||||||||||||||||||||||||||
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| Phone | +1 512-730-3060 |
| Phone | +1 904-627-2900 |
| Fax | 9042533098 |
Authorized person
| Name | RYAN CARLETTI |
| Role | VICE PRESIDENT |
| Phone | 3307273530 |
Taxonomy
| Taxonomy Code | 207RC0200X - Critical Care Medicine (Internal Medicine) Physician |
| Is Primary | Yes |
| Taxonomy Code | 207RP1001X - Pulmonary Disease Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 022274400 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| Pulido Juan D | Auth | 7500 Rialto Blvd., Bldg. 1, Austin, TX, 78735 |
| HNI OF FLORIDA, INC. | Auth | No data |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-08 | 2624 Atlantic Bouvelard, Suite 6, Jacksonville, FL 32207 | No data |
| CHANGE OF MAILING ADDRESS | 2019-09-12 | 2624 Atlantic Bouvelard, Suite 6, Jacksonville, FL 32207 | No data |
| REGISTERED AGENT NAME CHANGED | 2019-09-12 | Corporation Service Company | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-09-12 | 1201 Hayes Street, Tallahassee, FL 32301 | No data |
| LC AMENDMENT AND NAME CHANGE | 2018-04-12 | JACKSONVILLE LUNG CLINIC, LLC | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-08 |
| ANNUAL REPORT | 2023-03-07 |
| ANNUAL REPORT | 2022-06-01 |
| ANNUAL REPORT | 2021-05-01 |
| ANNUAL REPORT | 2020-07-22 |
| ANNUAL REPORT | 2019-09-12 |
| LC Amendment and Name Change | 2018-04-12 |
| Florida Limited Liability | 2018-01-08 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
