| Entity Name: | MYRTLE RIDGE HEALTHCARE CENTER LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 03 Feb 2020 (5 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 04 Jun 2020 (5 years ago) |
| Document Number: | L20000039154 |
| FEI/EIN Number | 84-4670483 |
| Address: | 1539 DALE MABRY HWY, #102, LUTZ, FL, 33548 |
| Mail Address: | 1539 DALE MABRY HWY, #102, LUTZ, FL, 33548 |
| ZIP code: | 33548 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1376170225 | 2020-03-23 | 2020-03-23 | 1539 DALE MABRY HWY STE 102, LUTZ, FL, 335483008, US | 1539 DALE MABRY HWY STE 102, LUTZ, FL, 335483008, US | |||||||||||||||||||
|
|||||||||||||||||||||||
| Phone | +1 813-909-7102 |
Authorized person
| Name | JAVIER GUTIERREZ |
| Role | EXECUTIVE OFFICER |
| Phone | 8139979543 |
Taxonomy
| Taxonomy Code | 363LA2200X - Adult Health Nurse Practitioner |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 102567000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MOGENA YUDAISY | Agent | 10618 DEERBERRY DR, LAND O LAKE, FL, 34638 |
| Name | Role | Address |
|---|---|---|
| MOGENA YUDAISY | Authorized Member | 10618 DEERBERRY DR, LAND O LAKE, FL, 34638 |
| DORTA GEORGE M | Authorized Member | 10618 DEERBERRY DR, LAND O LAKE, FL, 34638 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2020-06-04 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-04-04 |
| ANNUAL REPORT | 2022-04-28 |
| ANNUAL REPORT | 2021-04-30 |
| LC Amendment | 2020-06-04 |
| Florida Limited Liability | 2020-02-03 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
