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SPACE COAST PODIATRY, LLC

Company Details

Entity Name: SPACE COAST PODIATRY, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Company
Status: Active
Date Filed: 25 Jan 2024 (a year ago)
Document Number: L24000047058
Address: 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935 UN
Mail Address: 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935 UN
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1740037597 2024-04-30 2024-09-09 6100 MINTON RD NW STE 101, PALM BAY, FL, 329071900, US 6100 MINTON RD NW STE 101, PALM BAY, FL, 329071900, US

Contacts

Phone +1 321-802-4075

Authorized person

Name DR. MARK ALLEN VAUGHN
Role CEO/PHYSICIAN
Phone 3218024075

Taxonomy

Taxonomy Code 213ES0103X - Foot & Ankle Surgery Podiatrist
Is Primary Yes

Agent

Name Role Address
VAUGHN, MARK Agent 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935

Manager

Name Role Address
VAUGHN, MARK Manager 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935 UN
VAUGHN, RAYCHEL L Manager 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935 UN

Documents

Name Date
Florida Limited Liability 2024-01-25

Date of last update: 08 Jan 2025

Sources: Florida Department of State