| Entity Name: | VIVANT MEDICAL GROUP LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 22 Jun 2020 (5 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 04 Nov 2024 (3 months ago) |
| Document Number: | L20000173928 |
| FEI/EIN Number | APPLIED FOR |
| Mail Address: | 15600 HANCOCK ROAD, SARASOTA, FL, 34240 |
| Address: | 6214 Memorial Hyw, Ste B, Tampa, FL, 33615, US |
| ZIP code: | 33615 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124652425 | 2020-02-25 | 2021-07-06 | 6214 MEMORIAL HWY STE B, TAMPA, FL, 336154507, US | 6214 MEMORIAL HWY STE B, TAMPA, FL, 336154507, US | |||||||||||||||||||||
|
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| Phone | +1 800-574-9491 |
| Fax | 8005472802 |
Authorized person
| Name | DAPHNEE MOISE-JOHNSON |
| Role | PRESIDENT |
| Phone | 8005749491 |
Taxonomy
| Taxonomy Code | 208D00000X - General Practice Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 273932100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Moise Daphnee | Agent | 15600 HANCOCK ROAD, SARASOTA, FL, 34240 |
| Name | Role | Address |
|---|---|---|
| MOISE-JOHNSON DAPHNEE | Manager | 15600 HANCOCK ROAD, SARASOTA, FL, 34240 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-11-04 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| REINSTATEMENT | 2023-04-03 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2021-10-06 | Moise, Daphnee | No data |
| REINSTATEMENT | 2021-10-06 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-10-06 | 6214 Memorial Hyw, Ste B, Tampa, FL 33615 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-11-04 |
| REINSTATEMENT | 2023-04-03 |
| REINSTATEMENT | 2021-10-06 |
| Florida Limited Liability | 2020-06-22 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
