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 |
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 | |||||||||||||
|
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 |
Name | Role | Address |
---|---|---|
VAUGHN, MARK | Agent | 2962 PEBBLE CREEK STREET, MELBOURNE, FL 32935 |
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 |
Name | Date |
---|---|
Florida Limited Liability | 2024-01-25 |
Date of last update: 08 Jan 2025
Sources: Florida Department of State