| Entity Name: | NORTH FLORIDA CANCER CENTER LAKE CITY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Company |
| Status: | Active |
| Date Filed: | 07 Jan 2005 (20 years ago) |
| Document Number: | M05000000121 |
| FEI/EIN Number | 52-2448736 |
| Address: | ONE PARK PLAZA, NASHVILLE, TN 37203 |
| Mail Address: | ONE PARK PLAZA, LEGAL DEPARTMENT, NASHVILLE, TN 37203 |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902893902 | 2005-10-04 | 2012-05-01 | 795 SW STATE ROAD 47, LAKE CITY, FL, 320250453, US | 795 SW HIGHWAY 47, LAKE CITY, FL, 32025, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 386-758-7822 |
| Fax | 3867582224 |
Authorized person
| Name | JOAN R GLADNEY |
| Role | REGIONAL DIRECTOR |
| Phone | 3524746190 |
Taxonomy
| Taxonomy Code | 2085R0001X - Radiation Oncology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 272085000 |
| State | FL |
| Issuer | BCBS |
| Number | 74629 |
| State | FL |
| Issuer | RR MEDICARE |
| Number | DD1689 |
| State | FL |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Foster, Jon M. | Manager | ONE PARK PLAZA, NASHVILLE, TN 37203 |
| HAZEN, SAMUEL N | Manager | ONE PARK PLAZA, NASHVILLE, TN 37203 |
| WYATT, CHRISTOPHER F | Manager | ONE PARK PLAZA, NASHVILLE, TN 37203 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G10000110261 | THE CANCER CENTER AT LAKE CITY | ACTIVE | 2010-12-03 | 2025-12-31 | No data | ONE PARK PLAZA, LEGAL DEPARTMENT, NASHVILLE, TN, 37203 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2011-08-11 | ONE PARK PLAZA, NASHVILLE, TN 37203 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2006-04-24 | ONE PARK PLAZA, NASHVILLE, TN 37203 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-16 |
| ANNUAL REPORT | 2023-04-18 |
| ANNUAL REPORT | 2022-04-22 |
| ANNUAL REPORT | 2021-04-26 |
| ANNUAL REPORT | 2020-04-29 |
| ANNUAL REPORT | 2019-04-17 |
| ANNUAL REPORT | 2018-04-17 |
| ANNUAL REPORT | 2017-04-21 |
| ANNUAL REPORT | 2016-04-22 |
| ANNUAL REPORT | 2015-04-21 |
Date of last update: 04 Jan 2025
Sources: Florida Department of State
