| Entity Name: | OLYMPIA MEDICAL GROUP LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 18 Jan 2018 (7 years ago) |
| Document Number: | L18000016241 |
| FEI/EIN Number | 82-4086350 |
| Address: | 2306 NORTH BLVD, SUITE C, DAVENPORT, FL, 33837, US |
| Mail Address: | 2306 NORTH BLVD, SUITE A, DEVENPORT, FL, 33837, US |
| ZIP code: | 33837 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1013473495 | 2019-02-11 | 2023-12-22 | 2306 NORTH BLVD W STE C, DAVENPORT, FL, 338378976, US | 2306 NORTH BLVD W STE C, DAVENPORT, FL, 338378976, US | |||||||||||||||||||||||||
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| Phone | +1 863-547-9200 |
Authorized person
| Name | BALA KODE |
| Role | MANAGING PARTNER |
| Phone | 8635479200 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 105446600 |
| State | FL |
| Issuer | CLINIC LICENSE |
| Number | HCC11921 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KODE BALA | Agent | 2306 NORTH BLVD W. SUITE B, DAVENPORT, FL, 33837 |
| Name | Role | Address |
|---|---|---|
| KODE BALA | President | 2306 NORTH BLVD W. SUITE C, DAVENPORT, FL, 33837 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-01-09 | 2306 NORTH BLVD, SUITE C, DAVENPORT, FL 33837 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-03-07 | 2306 NORTH BLVD W. SUITE B, DAVENPORT, FL 33837 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-09 |
| ANNUAL REPORT | 2023-03-10 |
| ANNUAL REPORT | 2022-04-11 |
| ANNUAL REPORT | 2021-04-30 |
| ANNUAL REPORT | 2020-03-12 |
| ANNUAL REPORT | 2019-03-07 |
| Florida Limited Liability | 2018-01-18 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
