| Entity Name: | OBSIDIAN HEALTHCARE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 20 Nov 2020 (4 years ago) |
| Document Number: | L20000368528 |
| FEI/EIN Number | 86-1215151 |
| Address: | 3379 Woolbright Rd, Boynton Beach, FL, 33436, US |
| Mail Address: | 3379 Woolbright Rd, Boynton Beach, FL, 33436, US |
| ZIP code: | 33436 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1447958699 | 2023-02-17 | 2023-02-17 | 3379 W WOOLBRIGHT RD, BOYNTON BEACH, FL, 334367245, US | 3379 W WOOLBRIGHT RD, BOYNTON BEACH, FL, 334367245, US | |||||||||||||||||||||
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| Phone | +1 561-449-0066 |
| Fax | 5618342511 |
Authorized person
| Name | MR. JUDE ACLOQUE |
| Role | AUTHORIZED OFFICIAL |
| Phone | 5614430066 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | LICENSE |
| Number | ME133297 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ACLOQUE JUDE A | Agent | 9674 Campi Dr., Lake Worth, FL, 33467 |
| Name | Role | Address |
|---|---|---|
| ACLOQUE JUDE A | Manager | 9674 Campi Dr., Lake Worth, FL, 33467 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000094221 | LAVA STONE HEALTHCARE AND CONSULTING | ACTIVE | 2023-08-11 | 2028-12-31 | No data | 9674 CAMPI DR, LAKE WORTH, FL, 33467 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-19 | 3379 Woolbright Rd, Boynton Beach, FL 33436 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-19 | 3379 Woolbright Rd, Boynton Beach, FL 33436 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-03-07 | 9674 Campi Dr., Lake Worth, FL 33467 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-19 |
| ANNUAL REPORT | 2023-01-25 |
| ANNUAL REPORT | 2022-03-07 |
| ANNUAL REPORT | 2021-03-17 |
| Florida Limited Liability | 2020-11-20 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
