| Entity Name: | INTERVENTIONAL SPINE AND PAIN INSTITUTE, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 29 Dec 2021 (3 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 18 Mar 2022 (3 years ago) |
| Document Number: | L22000007931 |
| FEI/EIN Number | 874307659 |
| Address: | 777 37 ST STE C-101, VERO BEACH, FL, 32960 |
| Mail Address: | 777 37 ST STE C-101, VERO BEACH, FL, 32960 |
| ZIP code: | 32960 |
| County: | Indian River |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1396526901 | 2023-10-10 | 2024-02-27 | 777 37TH ST STE C101, VERO BEACH, FL, 329607301, US | 5200 BABCOCK ST NE STE 111, PALM BAY, FL, 329054639, US | |||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||
| Phone | +1 772-360-1997 |
| Fax | 7724923541 |
Authorized person
| Name | PHAEDRA LUND SHUDRA |
| Role | CREDENTIALING AND CONTRACTING SPECI |
| Phone | 8137854861 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| Is Primary | No |
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| Is Primary | No |
| Taxonomy Code | 207RH0002X - Hospice and Palliative Medicine (Internal Medicine) Physician |
| Is Primary | No |
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| GASSMAN ALAN SESQ. | Agent | 1245 COURT STREET, CLEARWATER, FL, 33756 |
| Name | Role | Address |
|---|---|---|
| ESPOSITO MICHAEL F | Manager | 777 37 ST STE C-101, VERO BEACH, FL, 32960 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2022-03-18 | No data | No data |
| LC AMENDMENT | 2022-01-21 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2022-01-21 | 777 37 ST STE C-101, VERO BEACH, FL 32960 | No data |
| CHANGE OF MAILING ADDRESS | 2022-01-21 | 777 37 ST STE C-101, VERO BEACH, FL 32960 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-01 |
| ANNUAL REPORT | 2023-01-09 |
| LC Amendment | 2022-03-18 |
| LC Amendment | 2022-01-21 |
| Florida Limited Liability | 2021-12-29 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
