| Entity Name: | IMAGINE PEDIATRICS OF FLORIDA LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 12 Sep 2022 (2 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 06 Feb 2024 (a year ago) |
| Document Number: | L22000398459 |
| FEI/EIN Number | 92-0754861 |
| Address: | 3109 Martin Luther King Jr. Blvd., Suite 350, Tampa, FL 33607 |
| Mail Address: | 3109 Martin Luther King Jr. Blvd., Suite 350, Tampa, FL 33607 |
| ZIP code: | 33607 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104542232 | 2022-10-19 | 2024-02-06 | 220 ATHENS WAY STE 240, NASHVILLE, TN, 372281311, US | 3109 W DR MARTIN LUTHER KING JR BLVD STE 350, TAMPA, FL, 336076208, US | |||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 504-470-4140 |
| Phone | +1 833-208-7770 |
Authorized person
| Name | KENNETH TAYLOR BEERY |
| Role | CHIEF ADMIN. OFFICER (CAO) |
| Phone | 5044704140 |
Taxonomy
| Taxonomy Code | 104100000X - Social Worker |
| Is Primary | No |
| Taxonomy Code | 106H00000X - Marriage & Family Therapist |
| Is Primary | No |
| Taxonomy Code | 133V00000X - Registered Dietitian |
| Is Primary | No |
| Taxonomy Code | 183500000X - Pharmacist |
| Is Primary | No |
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LP0200X - Pediatric Nurse Practitioner |
| Is Primary | No |
| Taxonomy Code | 363LP0222X - Critical Care Pediatric Nurse Practitioner |
| Is Primary | No |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Imagine Pediatrics Provider Holdings, PLLC | Sole Member | 220 Athens Way, Suite 240 Nashville, TN 37228 |
| Name | Role | Address |
|---|---|---|
| Hayes, Patricia, M.D. | President | 3109 Martin Luther King Jr. Blvd., Suite 350 Tampa, FL 33607 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-15 | 3109 Martin Luther King Jr. Blvd., Suite 350, Tampa, FL 33607 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-15 | 3109 Martin Luther King Jr. Blvd., Suite 350, Tampa, FL 33607 | No data |
| LC STMNT OF RA/RO CHG | 2024-02-06 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2024-02-06 | C T CORPORATION SYSTEM | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-02-06 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| LC AMENDMENT AND NAME CHANGE | 2022-10-20 | IMAGINE PEDIATRICS OF FLORIDA LLC | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-06-19 |
| ANNUAL REPORT | 2024-04-15 |
| CORLCRACHG | 2024-02-06 |
| ANNUAL REPORT | 2023-04-27 |
| LC Amendment and Name Change | 2022-10-20 |
| Florida Limited Liability | 2022-09-12 |
Date of last update: 11 Feb 2025
Sources: Florida Department of State
