| Entity Name: | BENJAMIN DEVRIES DO LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 18 Jul 2019 (6 years ago) |
| Document Number: | L19000185732 |
| FEI/EIN Number | 84-2365992 |
| Address: | 1573 S FT HARRISON AVE., CLEARWATER, FL, 33753 |
| Mail Address: | 1573 S FT HARRISON AVE., CLEARWATER, FL, 33753 |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558916494 | 2019-08-07 | 2020-08-11 | 1573 S FORT HARRISON AVE, CLEARWATER, FL, 337562004, US | 1573 S FORT HARRISON AVE, CLEARWATER, FL, 337562004, US | |||||||||||||||||||||||||||
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| Phone | +1 727-584-8777 |
Authorized person
| Name | BENJAMIN DEVRIES |
| Role | OWNER |
| Phone | 3192396395 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 261Q00000X - Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 72062 |
| Issuer | MEDICAID |
| Number | 103871800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DEVRIES BENJAMIN R | Agent | 11192 HARBORSIDE DR., LARGO, FL, 33773 |
| Name | Role | Address |
|---|---|---|
| DEVRIES BENJAMIN | Manager | 11192 HARBORSIDE DR, LARGO, FL, 33773 |
| Name | Role | Address |
|---|---|---|
| DeVries Lynn | Authorized Representative | 11192 Harborside Dr, Largo, FL, 33773 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-17 |
| ANNUAL REPORT | 2023-02-18 |
| ANNUAL REPORT | 2022-01-28 |
| ANNUAL REPORT | 2021-04-28 |
| ANNUAL REPORT | 2020-03-17 |
| Florida Limited Liability | 2019-07-18 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
