| Entity Name: | FONSECA PEDIATRICS LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 12 Sep 2022 (2 years ago) |
| Document Number: | L22000398590 |
| FEI/EIN Number | 92-0352050 |
| Address: | 2801 17th St, Unit 102, Saint Cloud, FL 34769 |
| Mail Address: | 2801 17th St, Unit 102, Saint Cloud, FL 34769 |
| ZIP code: | 34769 |
| County: | Osceola |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881475762 | 2023-10-09 | 2024-04-11 | 2801 17TH ST UNIT 102, SAINT CLOUD, FL, 347694939, US | 2801 17TH ST UNIT 102, SAINT CLOUD, FL, 347694939, US | |||||||||||||||||||||||||||
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| Phone | +1 407-519-2930 |
| Fax | 4075563565 |
Authorized person
| Name | RAMON AUGUSTO FONSECA |
| Role | OWNER |
| Phone | 4077296068 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD NUMBER |
| Number | V95A6 |
| State | FL |
| Issuer | MEDICAID |
| Number | 120425200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FONSECA , RAMON | Agent | 2898 PARTIN SETTLEMENT ROAD, KISSIMMEE, FL 34744 |
| Name | Role | Address |
|---|---|---|
| FONSECA, RAMON | Authorized Member | 2898 PARTIN SETTLEMENT ROAD, KISSIMMEE, FL 34744 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-25 | 2801 17th St, Unit 102, Saint Cloud, FL 34769 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-25 | 2801 17th St, Unit 102, Saint Cloud, FL 34769 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-04-25 | FONSECA , RAMON | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-25 | 2898 PARTIN SETTLEMENT ROAD, KISSIMMEE, FL 34744 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-25 |
| ANNUAL REPORT | 2023-04-17 |
| Florida Limited Liability | 2022-09-12 |
Date of last update: 11 Feb 2025
Sources: Florida Department of State
