| Entity Name: | ISLAND DIRECT PRIMARY CARE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 02 Oct 2018 (6 years ago) |
| Document Number: | L18000233159 |
| FEI/EIN Number | 83-2113680 |
| Address: | 410 w merritt avenue, MERRITT ISLAND, FL, 32953, US |
| Mail Address: | 410 w merritt avenue, MERRITT ISLAND, FL, 32953, US |
| ZIP code: | 32953 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1811463961 | 2018-10-16 | 2022-03-27 | 210 HICKORY AVE, MERRITT ISLAND, FL, 329534368, US | 390 N COURTENAY PKWY, MERRITT ISLAND, FL, 329533456, US | |||||||||||||||||||
|
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| Phone | +1 321-506-2540 |
Authorized person
| Name | DR. JOHN WESLEY ROTHWELL III |
| Role | PRESIDENT |
| Phone | 3215062540 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1679943740 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ROTHWELL III JOHN W | Agent | 210 Hickory Avenue, Merritt Island, FL, 32953 |
| Name | Role | Address |
|---|---|---|
| Rothwell John WDr. | President | 210 Hickory Avenue, Merritt Island, FL, 32953 |
| Name | Role | Address |
|---|---|---|
| Rothwell Wendy L | Secretary | 210 Hickory Avenue, Merritt Island, FL, 32953 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000144857 | JWSOLUTIONS GROUP | ACTIVE | 2024-11-29 | 2029-12-31 | No data | 410 W MERRITT AVE, MERRITT ISLAND, FL, 32953 |
| G24000056337 | PRECISION 360 WELLNESS | ACTIVE | 2024-04-29 | 2029-12-31 | No data | 410 W MERRITT AVE, MERRITT ISLAND, FL, 32953 |
| G23000057648 | MAIN STREET DIRECT PRIMARY CARE LLC | ACTIVE | 2023-05-07 | 2028-12-31 | No data | 410 W MERRITT AVE, MERRITT ISLAND, FL, 32953 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-01-10 | 410 w merritt avenue, MERRITT ISLAND, FL 32953 | No data |
| CHANGE OF MAILING ADDRESS | 2022-01-10 | 410 w merritt avenue, MERRITT ISLAND, FL 32953 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-04-11 | 210 Hickory Avenue, Merritt Island, FL 32953 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-08 |
| ANNUAL REPORT | 2023-01-24 |
| ANNUAL REPORT | 2022-03-02 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-03-16 |
| ANNUAL REPORT | 2019-04-11 |
| Florida Limited Liability | 2018-10-02 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
