| Entity Name: | GRACELAND FAMILY PRACTICE PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Inactive |
| Date Filed: | 04 Aug 2020 (5 years ago) |
| Date of dissolution: | 25 Jan 2025 (a month ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 25 Jan 2025 (a month ago) |
| Document Number: | L20000224962 |
| FEI/EIN Number | 85-2408449 |
| Mail Address: | 6470 TIPPIN AVE, PENSACOLA, FL 32504 |
| Address: | 6470 Tippin Ave, PENSACOLA, FL 32504 |
| ZIP code: | 32504 |
| County: | Escambia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881293587 | 2020-10-22 | 2020-10-22 | 6470 TIPPIN AVE, PENSACOLA, FL, 325048143, US | 6470 TIPPIN AVE, PENSACOLA, FL, 325048143, US | |||||||||||||||||||
|
|||||||||||||||||||||||
| Phone | +1 850-741-2878 |
Authorized person
| Name | MRS. DEBRA ANN FICKLING |
| Role | PROVIDER |
| Phone | 8507412878 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1184196669 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FICKLING, SHANE, MGR | Agent | 6470 TIPPIN AVE., PENSACOLA, FL 32504 |
| Name | Role | Address |
|---|---|---|
| FICKLING, SHANE | Manager | 6470 TIPPIN AVE, PENSACOLA, FL 32504 |
| FICKLING, DEBRA | Manager | 6470 TIPPIN AVE, PENSACOLA, FL 32504 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-02-05 | FICKLING, SHANE, MGR | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-10-30 | 6470 Tippin Ave, PENSACOLA, FL 32504 | No data |
| LC AMENDMENT | 2020-10-29 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2020-10-29 | 6470 Tippin Ave, PENSACOLA, FL 32504 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-10-29 | 6470 TIPPIN AVE., PENSACOLA, FL 32504 | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2025-01-25 |
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-02-13 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-04-09 |
| LC Amendment | 2020-10-29 |
| Florida Limited Liability | 2020-08-04 |
Date of last update: 14 Feb 2025
Sources: Florida Department of State
