| Entity Name: | GRACE FAMILY PRACTICE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 31 Aug 2020 (4 years ago) |
| Document Number: | L20000269985 |
| FEI/EIN Number | 85-2408449 |
| Address: | 6470 TIPPIN AVE, PENSACOLA, FL 32504 |
| Mail 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 | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1932708617 | 2020-10-22 | 2020-10-22 | 6470 TIPPIN AVE, PENSACOLA, FL, 325048143, US | 6470 TIPPIN AVE, PENSACOLA, FL, 325048143, US | |||||||||||||||||||
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| 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 P | Agent | 6470 Tippin Ave, Pensacola, FL 32504 |
| Name | Role | Address |
|---|---|---|
| FICKLING, SHANE P, MGR | Manager | 1920 JOHN CARROLL DR, PENSACOLA, FL 32504 |
| FICKLING, DEBRA ANN | Manager | 1920 John Carroll Dr., Pensacola, FL 32504 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2022-04-29 | 6470 TIPPIN AVE, PENSACOLA, FL 32504 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-04-29 | 6470 Tippin Ave, Pensacola, FL 32504 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-07-03 | FICKLING, SHANE P | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-02-13 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-07-03 |
| Florida Limited Liability | 2020-08-31 |
Date of last update: 14 Feb 2025
Sources: Florida Department of State
