| Entity Name: | MIND REVIVE PSYCHIATRY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 16 Nov 2020 (4 years ago) |
| Document Number: | L20000362867 |
| FEI/EIN Number | 85-3907467 |
| Address: | 4755 Drane Field Road #103, LAKELAND, FL, 33811, US |
| Mail Address: | 4755 Drane Field Road #103, LAKELAND, FL, 33811, US |
| ZIP code: | 33811 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1285230185 | 2020-12-07 | 2023-08-22 | PO BOX 640, AUBURNDALE, FL, 338230640, US | 1863 SKYVIEW DR, AUBURNDALE, FL, 338235445, US | |||||||||||||||||||||||
|
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| Phone | +1 407-561-2500 |
| Fax | 8334102620 |
Authorized person
| Name | MR. MARCUS L ROBINSON |
| Role | PSYCHIATRIC NURSE PRACTITIONER |
| Phone | 8633992664 |
Taxonomy
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | No |
| Taxonomy Code | 261QM0855X - Adolescent and Children Mental Health Clinic/Center |
| Is Primary | No |
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| ROBINSON MARCUS | Agent | 4755 Drane Field Road #103, LAKELAND, FL, 33811 |
| Name | Role | Address |
|---|---|---|
| ROBINSON MARCUS | Manager | 4755 Drane Field Road #103, LAKELAND, FL, 33811 |
| Name | Role | Address |
|---|---|---|
| Robinson Delonique J | Auth | 4755 Drane Field Rd #103, Lakeland, FL, FL, 33811 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2023-01-05 | 4755 Drane Field Road #103, LAKELAND, FL 33811 | No data |
| CHANGE OF MAILING ADDRESS | 2022-11-15 | 4755 Drane Field Road #103, LAKELAND, FL 33811 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2022-11-14 | 4755 Drane Field Road #103, LAKELAND, FL 33811 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-13 |
| ANNUAL REPORT | 2023-01-05 |
| ANNUAL REPORT | 2022-03-14 |
| Florida Limited Liability | 2020-11-16 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
