| Entity Name: | THE LAKELAND FL ENDOSCOPY ASC, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 25 Feb 2004 (21 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 17 May 2017 (8 years ago) |
| Document Number: | M04000000772 |
| FEI/EIN Number | 200288888 |
| Mail Address: | 541 S. Florida Ave, Lakeland, FL, 33801, US |
| Address: | 3340 Lakeland Hills BLVD, Lakeland, FL, 33805, US |
| ZIP code: | 33805 |
| County: | Polk |
| Place of Formation: | TENNESSEE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1649244567 | 2006-02-15 | 2023-09-07 | 3340 LAKELAND HILLS BLVD, LAKELAND, FL, 338051974, US | 3340 LAKELAND HILLS BLVD, LAKELAND, FL, 338051974, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 863-682-3239 |
| Fax | 8636823462 |
Authorized person
| Name | MR. PHILLIP A CLENDENIN |
| Role | PRESIDENT |
| Phone | 6156651283 |
Taxonomy
| Taxonomy Code | 261QA1903X - Ambulatory Surgical Clinic/Center |
| License Number | 1230 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RAILROAD MEDICARE |
| Number | P00221727 |
| State | FL |
| Issuer | MEDICAID |
| Number | 075976700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Khan Saqib Dr. | Agent | 541 S Florida Ave, Lakeland, FL, 33801 |
| Name | Role | Address |
|---|---|---|
| Khan Saqib Dr. | President | 541 S. Florida Ave, Lakeland, FL, 33801 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000018062 | SURGERY CENTER OF LAKELAND HILLS BOULEVARD | ACTIVE | 2023-02-07 | 2028-12-31 | No data | 3340 LAKELAND HILLS BOULEVARD, LAKELAND, FL, 33805 |
| G11000011135 | SURGERY CENTER OF LAKELAND HILLS BOULEVARD | EXPIRED | 2011-01-28 | 2016-12-31 | No data | 20 BURTON HILLS BLVD., SUITE 500, NASHVILLE, TN, 37215 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-01-26 | 3340 Lakeland Hills BLVD, Lakeland, FL 33805 | No data |
| CHANGE OF MAILING ADDRESS | 2022-01-26 | 3340 Lakeland Hills BLVD, Lakeland, FL 33805 | No data |
| REGISTERED AGENT NAME CHANGED | 2022-01-26 | Khan, Saqib, Dr. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-01-26 | 541 S Florida Ave, Lakeland, FL 33801 | No data |
| LC STMNT OF RA/RO CHG | 2017-05-17 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-01-20 |
| ANNUAL REPORT | 2022-01-26 |
| ANNUAL REPORT | 2021-04-29 |
| ANNUAL REPORT | 2020-06-03 |
| ANNUAL REPORT | 2019-04-25 |
| ANNUAL REPORT | 2018-04-25 |
| CORLCRACHG | 2017-05-17 |
| ANNUAL REPORT | 2017-04-20 |
| ANNUAL REPORT | 2016-03-30 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
