| Entity Name: | MEMORIAL SOUTHSIDE CANCER CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 29 Nov 2005 (19 years ago) |
| Date of dissolution: | 28 Feb 2023 (2 years ago) |
| Last Event: | WITHDRAWAL |
| Event Date Filed: | 28 Feb 2023 (2 years ago) |
| Document Number: | M05000006565 |
| FEI/EIN Number | 760807743 |
| Address: | 2270 COLONIAL BOULEVARD, FT. MYERS, FL, 33907, US |
| Mail Address: | 2270 COLONIAL BOULEVARD, FT. MYERS, FL, 33907, US |
| ZIP code: | 33907 |
| County: | Lee |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1588724033 | 2006-12-12 | 2010-01-27 | 5742 BOOTH RD, SUITE B, JACKSONVILLE, FL, 32207, US | 5742 BOOTH RD, SUITE B, JACKSONVILLE, FL, 32207, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 904-636-6911 |
| Fax | 9046366330 |
Authorized person
| Name | MR. LAVELLE HARDIN |
| Role | CREDENTIALING COORDINATOR |
| Phone | 6153448203 |
Taxonomy
| Taxonomy Code | 261QX0203X - Radiation Oncology Clinic/Center |
| License Number | APPLYING |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RR MEDICARE |
| Number | DG1361 |
| State | FL |
| Issuer | BCBS OF FL |
| Number | 00389 |
| State | FL |
| Issuer | MEDICAID |
| Number | 277325200 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role |
|---|---|
| GENESISCARE USA, INC. | Member |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| WITHDRAWAL | 2023-02-28 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2015-08-25 | 2270 COLONIAL BOULEVARD, FT. MYERS, FL 33907 | No data |
| CHANGE OF MAILING ADDRESS | 2015-08-25 | 2270 COLONIAL BOULEVARD, FT. MYERS, FL 33907 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-12-06 | 1201 HAYS STREET, TALLAHASSEE, FL 32301 | No data |
| REGISTERED AGENT NAME CHANGED | 2012-12-06 | CORPORATION SERVICE COMPANY | No data |
| REINSTATEMENT | 2012-12-06 | No data | No data |
| REVOKED FOR ANNUAL REPORT | 2012-09-28 | No data | No data |
| Name | Date |
|---|---|
| WITHDRAWAL | 2023-02-28 |
| AMENDED ANNUAL REPORT | 2022-05-10 |
| ANNUAL REPORT | 2022-04-21 |
| ANNUAL REPORT | 2021-04-19 |
| ANNUAL REPORT | 2020-01-17 |
| AMENDED ANNUAL REPORT | 2019-10-15 |
| ANNUAL REPORT | 2019-04-30 |
| ANNUAL REPORT | 2018-04-24 |
| ANNUAL REPORT | 2017-01-11 |
| ANNUAL REPORT | 2016-04-25 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
