| Entity Name: | ROGER ROQUE MD LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 18 Apr 2022 (3 years ago) |
| Document Number: | L22000184121 |
| FEI/EIN Number | 88-1809414 |
| Address: | 620 S LAKE ST., SUITE 2, LEESBURG, FL, 34748, US |
| Mail Address: | P.O. BOX 491500, LEESBURG, FL, 34748, US |
| ZIP code: | 34748 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1205571015 | 2022-05-05 | 2023-02-03 | PO BOX 491500, LEESBURG, FL, 347491500, US | 620 S LAKE ST STE 2, LEESBURG, FL, 347486059, US | |||||||||||||||||
|
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| Phone | +1 352-314-6589 |
Authorized person
| Name | MR. DAVID P WAGNER |
| Role | CHIEF FINANCIAL OFFICER |
| Phone | 3212045222 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 261QM1300X - Multi-Specialty Clinic/Center |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| WAGNER DAVID P | Agent | 700 WEST MAIN ST, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| SALVADOR-BACKER YESENIA | Manager | 109 N 7TH ST, LEESBURG, FL, 34748 |
| Name | Role |
|---|---|
| PATHWAYS HEALTHCARE GROUP, LLC | Authorized Member |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000113122 | CLINICA FAMILIAR | ACTIVE | 2024-09-10 | 2029-12-31 | No data | PO BOX 491500, LEESBURG, FL, 34749 |
| G22000057073 | ST FRANCIS PRIMARY CARE CLINIC | ACTIVE | 2022-05-05 | 2027-12-31 | No data | POBOX 491500, LEESBURG, FL, 34749 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2022-07-25 | 620 S LAKE ST., SUITE 2, LEESBURG, FL 34748 | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-05-22 |
| ANNUAL REPORT | 2024-01-26 |
| ANNUAL REPORT | 2023-01-12 |
| Florida Limited Liability | 2022-04-18 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
