| Entity Name: | SOUTHEAST VOLUSIA MEDICAL SERVICES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 18 Oct 1994 (30 years ago) |
| Document Number: | N94000005152 |
| FEI/EIN Number | 593287185 |
| Address: | 909 Carey Drive, South Daytona, FL, 32119, US |
| Mail Address: | PO BOX 909, NEW SMYRNA BEACH, FL, 32170, US |
| ZIP code: | 32119 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1104868876 | 2006-06-10 | 2008-12-19 | PO BOX 919246, ORLANDO, FL, 328919246, US | 401 PALMETTO ST, NEW SMYRNA BEACH, FL, 321687322, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 386-424-5000 |
Authorized person
| Name | MR. AL ALLRED |
| Role | CPA FO |
| Phone | 3864245000 |
Taxonomy
| Taxonomy Code | 207P00000X - Emergency Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207RC0000X - Cardiovascular Disease Physician |
| Is Primary | No |
| Taxonomy Code | 207RR0500X - Rheumatology Physician |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | No |
| Taxonomy Code | 208600000X - Surgery Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2518567800 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Davidson Jeff | Agent | 909 Carey Drive, South Daytona, FL, 32119 |
| Name | Role | Address |
|---|---|---|
| Card Harold P | Secretary | 3019 Willow Oak Dr., EDGEWATER, FL, 32141 |
| Name | Role | Address |
|---|---|---|
| DAVIDSON JEFF | Chief Financial Officer | 909 Carey Drive, South Daytona, FL, 32119 |
| Name | Role | Address |
|---|---|---|
| Preston William | Chairman | 605 S. Orange Street, New Smyrna Beach, FL, 32168 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G10000010114 | CORONADO HEALTH PARTNERS | EXPIRED | 2010-02-01 | 2015-12-31 | No data | 401 PALMETTO STREET, NEW SMYRNA BEACH, FL, 32168 |
| G09042900045 | CORONADO NEUROLOGY | EXPIRED | 2009-02-11 | 2014-12-31 | No data | GLENN I. KOLLURI, M.D., 600 PALMETTO STREET, NEW SMYRNA BEACH, FL, 32168 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| NAME CHANGE AMENDMENT | 2008-02-05 | SOUTHEAST VOLUSIA MEDICAL SERVICES, INC. | No data |
| REINSTATEMENT | 2004-11-05 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2004-10-01 | No data | No data |
| NAME CHANGE AMENDMENT | 2002-12-04 | SOUTHEAST VOLUSIA SERVICES, INC. | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
