| Entity Name: | SPACE COAST ADVANCED PRACTICE CONSULTANTS LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 10 Dec 2018 (6 years ago) |
| Document Number: | L18000282934 |
| FEI/EIN Number | 83-2259836 |
| Address: | 1838 WADENA STREET NW, PALM BAY, FL, 32907, US |
| Mail Address: | PO BOX 60976, PALM BAY, FL, 32906, US |
| ZIP code: | 32907 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1477177004 | 2020-05-29 | 2020-05-29 | 1838 WADENA ST NW, PALM BAY, FL, 329078511, US | 115 HICKORY ST STE 204, MELBOURNE, FL, 329043505, US | |||||||||||||||||||
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| Phone | +1 321-795-7386 |
Authorized person
| Name | MS. LAKEECIA CANNION |
| Role | OWNER |
| Phone | 3217957386 |
Taxonomy
| Taxonomy Code | 261Q00000X - Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 016947100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CANNION LAKEECIA C | Agent | 1838 WADENA STREET NW, PALM BAY, FL, 32907 |
| Name | Role | Address |
|---|---|---|
| CANNION LAKEECIA C | Manager | 1838 WADENA STREET NW, PALM BAY, FL, 32907 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000051113 | EMBRACING YOU INTEGRATIVE MEDICINE | ACTIVE | 2020-05-08 | 2025-12-31 | No data | 1838 WADENA STREET NW, PALM BAY, FL, 32907 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2020-06-09 | 1838 WADENA STREET NW, PALM BAY, FL 32907 | No data |
| REGISTERED AGENT NAME CHANGED | 2020-06-09 | CANNION, LAKEECIA C | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-06 |
| ANNUAL REPORT | 2023-02-15 |
| ANNUAL REPORT | 2022-04-12 |
| ANNUAL REPORT | 2021-01-31 |
| ANNUAL REPORT | 2020-06-09 |
| Florida Limited Liability | 2018-12-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
