| Entity Name: | IMAGINE PEDIATRIC THERAPY OF BREVARD, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 09 Aug 2019 (6 years ago) |
| Last Event: | LC NAME CHANGE |
| Event Date Filed: | 29 Oct 2019 (5 years ago) |
| Document Number: | L19000203395 |
| FEI/EIN Number | 84-2748913 |
| Address: | 600 N SONORA CIR, INDIALANTIC, FL, 32903, US |
| Mail Address: | 600 N SONORA CIR, INDIALANTIC, FL, 32903, US |
| ZIP code: | 32903 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1942857511 | 2019-08-19 | 2021-06-19 | 600 N SONORA CIR, INDIALANTIC, FL, 329033735, US | 600 N SONORA CIR, INDIALANTIC, FL, 329033735, US | |||||||||||||||||||||||||||||||
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| Phone | +1 321-223-8791 |
| Fax | 3213738791 |
Authorized person
| Name | YELBA MERCEDES DELGADO |
| Role | SPEECH LANGUAGE PATHOLOGIST |
| Phone | 3212238791 |
Taxonomy
| Taxonomy Code | 235Z00000X - Speech-Language Pathologist |
| Is Primary | Yes |
| Taxonomy Code | 252Y00000X - Early Intervention Provider Agency |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 104044500 |
| State | FL |
| Issuer | MEDICAID |
| Number | 110199500 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DELGADO YELBA M | Agent | 600 N SONORA CIR, INDIALANTIC, FL, 32903 |
| Name | Role | Address |
|---|---|---|
| DELGADO YELBA M | Authorized Representative | 600 N SONORA CIR, INDIALANTIC, FL, 32903 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC NAME CHANGE | 2019-10-29 | IMAGINE PEDIATRIC THERAPY OF BREVARD, LLC | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-09 |
| ANNUAL REPORT | 2023-03-14 |
| ANNUAL REPORT | 2022-05-02 |
| ANNUAL REPORT | 2021-03-30 |
| ANNUAL REPORT | 2020-03-10 |
| LC Name Change | 2019-10-29 |
| Florida Limited Liability | 2019-08-09 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
