| Entity Name: | DR. PALES HEALTHCARE PROVIDER LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 15 Nov 2021 (3 years ago) |
| Document Number: | L21000490008 |
| FEI/EIN Number | 88-3105870 |
| Address: | 8390 Champions Gate Boulevard, SUITE 108, Champions Gate, FL 33896 |
| Mail Address: | 8390 Champions Gate Boulevard, Suite 108, Champions Gate, FL 33896 |
| ZIP code: | 33896 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891438321 | 2022-04-13 | 2024-11-07 | 8390 CHAMPIONS GATE BLVD, SUITE 108, CHAMPIONS GATE, FL, 33896, US | 8390 CHAMPIONS GATE BLVD, SUITE 108, CHAMPIONS GATE, FL, 33896, US | |||||||||||||||||||||
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| Phone | +1 407-683-9205 |
| Phone | +1 863-521-4497 |
Authorized person
| Name | PAOLA RAMIREZ |
| Role | MANAGER |
| Phone | 8635214497 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 116373400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PALES, CHRISTINE M, DR. | Agent | 8390 Champions Gate Boulevard, Suite 108, Champions Gate, FL 33896 |
| Name | Role | Address |
|---|---|---|
| PALES, CHRISTINE Marie, DR. | Manager | 8390 Champions Gate Boulevard, Suite 108 Champions Gate, FL 33896 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2023-07-12 | 8390 Champions Gate Boulevard, SUITE 108, Champions Gate, FL 33896 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-07-12 | 8390 Champions Gate Boulevard, Suite 108, Champions Gate, FL 33896 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2022-08-05 | 8390 Champions Gate Boulevard, SUITE 108, Champions Gate, FL 33896 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-06 |
| ANNUAL REPORT | 2023-07-12 |
| ANNUAL REPORT | 2022-03-05 |
| Florida Limited Liability | 2021-11-15 |
Date of last update: 12 Feb 2025
Sources: Florida Department of State
