| Entity Name: | SILOAM MEDICAL LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 15 Mar 2021 (4 years ago) |
| Document Number: | L21000121233 |
| FEI/EIN Number | 86-2836691 |
| Address: | 15123 Ogden Loop, Odessa, FL, 33556, US |
| Mail Address: | 15123 Ogden Loop, Odessa, FL, 33556, US |
| ZIP code: | 33556 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1154996072 | 2021-05-24 | 2023-09-14 | 15123 OGDEN LOOP, ODESSA, FL, 335564633, US | 15123 OGDEN LOOP, ODESSA, FL, 335564633, US | |||||||||||||||||||||||||||||||
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| Phone | +1 860-268-6617 |
Authorized person
| Name | NICHOLAS BOTTARO |
| Role | OWNER |
| Phone | 8602686617 |
Taxonomy
| Taxonomy Code | 207W00000X - Ophthalmology Physician |
| Is Primary | Yes |
| Taxonomy Code | 207WX0009X - Glaucoma Specialist (Ophthalmology) Physician |
| Is Primary | No |
| Taxonomy Code | 207WX0120X - Cornea and External Diseases Specialist Physician |
| Is Primary | No |
| Taxonomy Code | 207WX0200X - Ophthalmic Plastic and Reconstructive Surgery Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 108311400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BOTTARO NICHOLAS | Agent | 15123 Ogden loop, Odessa, FL, 33556 |
| Name | Role | Address |
|---|---|---|
| BOTTARO NICHOLAS | Manager | 15123 Ogden loop, Odessa, Fl, 33556 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000110134 | BEATIFIC VISION | ACTIVE | 2023-09-08 | 2028-12-31 | No data | 15123 OGDEN LOOP, ODESSA, FL, 33556 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2024-03-29 | 15123 Ogden loop, Odessa, FL 33556 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-09-18 | 15123 Ogden Loop, Odessa, FL 33556 | No data |
| CHANGE OF MAILING ADDRESS | 2023-09-18 | 15123 Ogden Loop, Odessa, FL 33556 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-29 |
| ANNUAL REPORT | 2023-01-21 |
| ANNUAL REPORT | 2022-01-27 |
| Florida Limited Liability | 2021-03-15 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
