| Entity Name: | FORT MYERS CHILDREN'S SURGERY CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 18 Apr 2023 (2 years ago) |
| Last Event: | LC AMENDMENT AND NAME CHANGE |
| Event Date Filed: | 28 Apr 2023 (2 years ago) |
| Document Number: | L23000192469 |
| FEI/EIN Number | 59-2430569 |
| Address: | 182 Industrial Road, Glen Rock, PA, 17327, US |
| Mail Address: | 182 Industrial Road, Glen Rock, PA, 17327, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366549511 | 2006-09-20 | 2023-11-21 | 182 INDUSTRIAL RD, GLEN ROCK, PA, 173278626, US | 3700 CENTRAL AVE, # 2, FT MYERS, FL, 33901, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 717-759-4375 |
| Fax | 7177594336 |
| Phone | +1 239-275-0665 |
| Fax | 2392750503 |
Authorized person
| Name | DEVIN LARSEN |
| Role | CEO |
| Phone | 2083401840 |
Taxonomy
| Taxonomy Code | 261QA1903X - Ambulatory Surgical Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RAILROAD MEDICARE |
| Number | 490000379 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CT CORPORATION SYSTEM | Agent | 1200 SOUTH PINE ISLAND RD, PLANTATION, FL, 33324 |
| Name | Role | Address |
|---|---|---|
| LARSEN DEVIN | Member | 182 Industrial Road, Glen Rock, PA, 17327 |
| SMYTHE DENNIS | Member | 182 Industrial Road, Glen Rock, PA, 17327 |
| Name | Role | Address |
|---|---|---|
| Figueroa Raymond D | Chief Executive Officer | 182 Industrial Road, Glen Rock, PA, 17327 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-23 | 182 Industrial Road, Glen Rock, PA 17327 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-23 | 182 Industrial Road, Glen Rock, PA 17327 | No data |
| LC AMENDMENT AND NAME CHANGE | 2023-04-28 | FORT MYERS CHILDREN'S SURGERY CENTER, LLC | No data |
| LC AMENDMENT | 2023-04-24 | No data | No data |
| CONVERSION | 2023-04-18 | No data | CORPORATION WAS A CONVERSION RESULT. CONVERTING CORPORATION WAS H06505. CONVERSION NUMBER 300000238913 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-23 |
| LC Amendment and Name Change | 2023-04-28 |
| LC Amendment | 2023-04-24 |
| Florida Limited Liability | 2023-04-17 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
