| Entity Name: | LAKE PLACID CHIROPRACTIC CLINIC, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 20 Jan 2000 (25 years ago) |
| Document Number: | P00000008866 |
| FEI/EIN Number | 650980085 |
| Address: | 2411 US 27 SO, SEBRING, FL, 33870 |
| Mail Address: | 2411 US 27 SO, SEBRING, FL, 33870 |
| ZIP code: | 33870 |
| County: | Highlands |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225263601 | 2009-05-28 | 2009-09-18 | 2411 US HIGHWAY 27 S, SEBRING, FL, 338704943, US | 2411 US HIGHWAY 27 S, SEBRING, FL, 338704943, US | |||||||||||||||||||||||||||||||
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| Phone | +1 863-382-9632 |
| Fax | 8633829632 |
Authorized person
| Name | DR. ROBERT T CLARK SR. |
| Role | OWNER |
| Phone | 8636996824 |
Taxonomy
| Taxonomy Code | 111N00000X - Chiropractor |
| License Number | CH7378 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 3814891-00 |
| State | FL |
| Issuer | BC/BS |
| Number | 55739 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| CLARK ROBERT T | Agent | 6100 HIGHLAND ST., SEBRING, FL, 33876 |
| Name | Role | Address |
|---|---|---|
| CLARK ROBERT T | President | 6100 HIGHLAND STREET, SEBRING, FL, 33876 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2011-10-03 | No data | No data |
| CANCEL ADM DISS/REV | 2009-10-08 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2009-09-25 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
