| Entity Name: | PALM BEACH PEDIATRICS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 12 Aug 2024 (6 months ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 12 Sep 2024 (5 months ago) |
| Document Number: | L24000363076 |
| FEI/EIN Number | 59-2724116 |
| Address: | 1920 PALM BEACH LAKES BLVD, SUITE 201, WEST PALM BEACH, FL 33405 |
| Mail Address: | 1920 PALM BEACH LAKES BLVD, SUITE 201, WEST PALM BEACH, FL 33405 |
| ZIP code: | 33405 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1629259072 | 2007-11-14 | 2022-11-07 | 1920 PALM BEACH LAKES BLVD STE 201, WEST PALM BEACH, FL, 334093506, US | 13475 SOUTHERN BLVD STE 202, LOXAHATCHEE GROVES, FL, 334709233, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 561-509-5009 |
| Fax | 5617381822 |
| Phone | +1 561-798-2468 |
| Fax | 5617982733 |
Authorized person
| Name | KIMBERLY BRENNAN |
| Role | PRACTICE ADMINISTRATOR |
| Phone | 5615095009 |
Taxonomy
| Taxonomy Code | 103T00000X - Psychologist |
| Is Primary | No |
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
| Taxonomy Code | 363LP0808X - Psychiatric/Mental Health Nurse Practitioner |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 379641800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FOX-LEVINE, SHANNON | Agent | 1920 PALM BEACH LAKES BLVD, SUITE 201, WEST PALM BEACH, FL 33405 |
| Name | Role | Address |
|---|---|---|
| FOX-LEVINE, SHANNON | MGRA | 1920 PALM BEACH LAKES BLVD, SUITE 201, WEST PALM BEACH, FL 33405 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2024-09-12 | No data | No data |
| CONVERSION | 2024-08-12 | No data | CORPORATION WAS A CONVERSION RESULT. CONVERTING CORPORATION WAS H79213. CONVERSION NUMBER 700000257647 |
| Name | Date |
|---|---|
| LC Amendment | 2024-09-12 |
| Florida Limited Liability | 2024-08-12 |
Date of last update: 07 Feb 2025
Sources: Florida Department of State
