| Entity Name: | IN BLOOM BIRTH AND WELLNESS PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 14 Oct 2020 (4 years ago) |
| Document Number: | L20000326321 |
| FEI/EIN Number | 85-3619808 |
| Address: | 2032 Siroco Lane, Melbourne, FL, 32934, US |
| Mail Address: | 2032 SIROCO LANE, MELBOURNE, FL, 32934, US |
| ZIP code: | 32934 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1649901992 | 2022-06-17 | 2024-04-11 | 2032 SIROCO LN, MELBOURNE, FL, 329347600, US | 1370 SARNO RD STE D, MELBOURNE, FL, 329355230, US | |||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||
| Phone | +1 321-312-1494 |
| Phone | +1 321-354-6911 |
| Fax | 3216175786 |
Authorized person
| Name | LINDA GAIL LEGAULT |
| Role | OWNER/PROVIDER |
| Phone | 3213121494 |
Taxonomy
| Taxonomy Code | 363LP2300X - Primary Care Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LW0102X - Women's Health Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LX0001X - Obstetrics & Gynecology Nurse Practitioner |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PROVIDER NPI |
| Number | 1740774470 |
| Issuer | APRN LICENSE # |
| Number | APRN11000324 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| IN BLOOM BIRTH AND WELLNESS, PLLC 401(K) PLAN | 2023 | 853619808 | 2024-05-28 | IN BLOOM BIRTH AND WELLNESS, PLLC | 0 | |||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-28 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2023-01-01 |
| Business code | 621498 |
| Sponsor’s telephone number | 3212666663 |
| Plan sponsor’s address | 1370 SARNO RD STE D, MELBOURNE, FL, 32935 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-11-13 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| LEGAULT LINDA G | Agent | 2032 SIROCO LANE, MELBOURNE, FL, 32934 |
| Name | Role | Address |
|---|---|---|
| LEGAULT LINDA G | Authorized Member | 2032 SIROCO LANE, MELBOURNE, FL, 32934 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-02-13 | 2032 Siroco Lane, Melbourne, FL 32934 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-13 |
| ANNUAL REPORT | 2023-03-04 |
| ANNUAL REPORT | 2022-04-23 |
| ANNUAL REPORT | 2021-01-26 |
| Florida Limited Liability | 2020-10-14 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
