| Entity Name: | FORT WALTON BEACH VISION CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 30 Jun 2021 (4 years ago) |
| Document Number: | L21000301635 |
| FEI/EIN Number | 87-1482029 |
| Address: | 113 NORTH PALAFOX STREET, PENSACOLA, FL 32514 |
| Mail Address: | 113 NORTH PALAFOX STREET, PENSACOLA, FL 32514 |
| ZIP code: | 32514 |
| County: | Escambia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225706112 | 2021-09-03 | 2024-03-15 | 36 EGLIN PKWY NE, FORT WALTON BEACH, FL, 325484915, US | 36 EGLIN PKWY NE, FORT WALTON BEACH, FL, 325484915, US | |||||||||||||||||||||||||||
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| Phone | +1 850-243-3111 |
| Fax | 8502004373 |
Authorized person
| Name | KATIE GILBERT SPEAR |
| Role | OWNER |
| Phone | 8505425133 |
Taxonomy
| Taxonomy Code | 152W00000X - Optometrist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 112470900 |
| State | FL |
| Issuer | FLORIDA BLUE |
| Number | WVMGV |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SPEAR, KATIE | Agent | 113 NORTH PALAFOX STREET, PENSACOLA, FL 32502 |
| Name | Role | Address |
|---|---|---|
| SPEAR, KATIE | Authorized Member | 113 NORTH PALAFOX STREET, PENSACOLA, FL 32502 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G21000153285 | THE VISION HUB AT DEFUNIAK SPRINGS | ACTIVE | 2021-11-16 | 2026-12-31 | No data | 113 NORTH PALAFOX STREET, PENSACOLA, FL, 32502 |
| G21000149470 | THE VISION HUB AT FT. WALTON BEACH | ACTIVE | 2021-11-08 | 2026-12-31 | No data | 113 NORTH PALAFOX STREET, PENSACOLA, FL, 32502 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-11 |
| ANNUAL REPORT | 2023-04-05 |
| ANNUAL REPORT | 2022-04-30 |
| Florida Limited Liability | 2021-06-30 |
Date of last update: 13 Feb 2025
Sources: Florida Department of State
