| Entity Name: | TEN BROECK JACKSONVILLE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 06 Apr 1999 (26 years ago) |
| Document Number: | L99000002041 |
| FEI/EIN Number | 593568978 |
| Address: | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Mail Address: | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| ZIP code: | 34786 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1497758312 | 2005-05-24 | 2008-05-08 | 6300 BEACH BLVD, JACKSONVILLE, FL, 322162708, US | 6300 BEACH BLVD, JACKSONVILLE, FL, 322162708, US | |||||||||||||||||||||||||
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| Phone | +1 904-724-9202 |
| Fax | 9047243797 |
Authorized person
| Name | MR. DAVID CORDDRY |
| Role | VICE PRESIDENT OF FINANCE |
| Phone | 4078762200 |
Taxonomy
| Taxonomy Code | 283Q00000X - Psychiatric Hospital |
| License Number | 4011 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 075144816 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BARKMAN KEVIN | Agent | 603 MAIN STREET, WINDERMERE, FL, 347861100 |
| Name | Role | Address |
|---|---|---|
| DIZNEY DONALD R | CAS | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Name | Role | Address |
|---|---|---|
| DIZNEY DAVID A | President | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Name | Role | Address |
|---|---|---|
| DIZNEY DAVID A | Chief Executive Officer | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Name | Role | Address |
|---|---|---|
| BARKMAN KEVIN | Executive Vice President | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Name | Role | Address |
|---|---|---|
| BARKMAN KEVIN | Secretary | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Name | Role | Address |
|---|---|---|
| CORDDRY DAVID | Vice President | 603 MAIN STREET, WINDERMERE, FL, 34786 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2018-04-24 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
