| Entity Name: | MINDFUL MEDICINE & COUNSELING CENTER LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 30 Jan 2023 (2 years ago) |
| Document Number: | L23000053644 |
| FEI/EIN Number | 92-2158270 |
| Address: | 10365 Hood Rd. S. #204, JACKSONVILLE, FL, 32257, US |
| Mail Address: | 10365 Hood Rd. S. #204, JACKSONVILLE, FL, 32257, US |
| ZIP code: | 32257 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1912693912 | 2023-04-12 | 2023-11-11 | 3914 DYLAN CT, JACKSONVILLE, FL, 322232707, US | 10365 HOOD RD S STE 204, JACKSONVILLE, FL, 322573261, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 217-480-7298 |
Authorized person
| Name | ROMAN CRIOLLO |
| Role | COO |
| Phone | 2174807298 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QM0855X - Adolescent and Children Mental Health Clinic/Center |
| Is Primary | No |
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | NPI NUMBER |
| Number | 1699834408 |
| State | FL |
| Issuer | MEDICAID |
| Number | 118398900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CRIOLLO ESMIRNA C | Agent | 3914 DYLAN COURT, JACKSONVILLE, FL, 32223 |
| Name | Role | Address |
|---|---|---|
| CRIOLLO ESMIRNA CMGR | Manager | 10365 HOOD RD. S., JACKSONVILLE, FL, 32257 |
| Name | Role | Address |
|---|---|---|
| CRIOLLO ROMAN UAP | Authorized Person | 3914 DYLAN CT, JACKSONVILLE, FL, 32223 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-19 | 10365 Hood Rd. S. #204, JACKSONVILLE, FL 32257 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-19 | 10365 Hood Rd. S. #204, JACKSONVILLE, FL 32257 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-04-19 | CRIOLLO, ESMIRNA C | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-19 | 3914 DYLAN COURT, JACKSONVILLE, FL 32223 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-19 |
| Florida Limited Liability | 2023-01-30 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
