| Entity Name: | LIVEACTIVE MULTISPECIALTY PHYSICIAN GROUP TAMPA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 07 Nov 2023 (a year ago) |
| Document Number: | L23000505708 |
| FEI/EIN Number | 93-4820982 |
| Address: | 12440 Cortez Blvd, Brooksville, FL 34613 |
| Mail Address: | 6650 W 110TH ST, SUITE 220A, LEAWOOD, KS 66211 |
| ZIP code: | 34613 |
| County: | Hernando |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891556049 | 2024-01-16 | 2024-09-14 | PO BOX 1269, BELLEVUE, NE, 680051269, US | 12440 CORTEZ BLVD, BROOKSVILLE, FL, 346132628, US | |||||||||||||||||
|
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| Phone | +1 913-549-3884 |
Authorized person
| Name | SHANE BRETHOWR |
| Role | CEO/AUTHORIZED OFFICIAL |
| Phone | 9135493884 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208M00000X - Hospitalist Physician |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| CT CORPORATION SYSTEM | Agent | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 |
| Name | Role | Address |
|---|---|---|
| LIVEACTIVE MANAGEMENT, LLC | Manager | 6650 W 110TH ST, STE 220A, LEAWOOD, KS 66211 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-06-26 | 12440 Cortez Blvd, Brooksville, FL 34613 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-06-26 |
| Florida Limited Liability | 2023-11-07 |
Date of last update: 08 Jan 2025
Sources: Florida Department of State
