| Entity Name: | PROVIDENCE MEDICAL CORPORATION |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 15 Feb 2000 (25 years ago) |
| Date of dissolution: | 25 Sep 2015 (9 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2015 (9 years ago) |
| Document Number: | P00000017293 |
| FEI/EIN Number | 593626517 |
| Address: | 3350 ULMERTON ROAD, SUITE 16, CLEARWATER, FL, 33762, US |
| Mail Address: | 3350 ULMERTON ROAD, SUITE 16, CLEARWATER, FL, 33762, US |
| ZIP code: | 33762 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225027493 | 2005-10-19 | 2014-08-26 | PO BOX 48833, ST PETERSBURG, FL, 337438833, US | 3350 ULMERTON RD, SUITE 16, CLEARWATER, FL, 337623397, US | |||||||||||||||||||||||||||||||
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| Phone | +1 727-540-9377 |
| Fax | 7275409387 |
Authorized person
| Name | MR. DAVID RICHARD LEVERING JR. |
| Role | PRESIDENT |
| Phone | 7275409377 |
Taxonomy
| Taxonomy Code | 332B00000X - Durable Medical Equipment & Medical Supplies |
| License Number | 326 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 022415400 |
| State | FL |
| Issuer | BCBS OF FLORIDA |
| Number | R9114 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| LEVERING PAMELA A | Agent | 3350 ULMERTON RD., CLEARWATER, FL, 33762 |
| Name | Role | Address |
|---|---|---|
| LEVERING DAVID R | Director | 3350 ULMERTON RD., SUITE 16, CLEARWATER, FL, 33762 |
| Name | Role | Address |
|---|---|---|
| LEVERING PAMELA A | Officer | 3350 ULMERTON RD., SUITE 16, CLEARWATER, FL, 33762 |
| BARNES JOSEPH L | Officer | 3350 ULMERTON RD., CLEARWATER, FL, 33762 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2011-06-22 | 3350 ULMERTON RD., SUITE 16, CLEARWATER, FL 33762 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2006-04-21 | 3350 ULMERTON ROAD, SUITE 16, CLEARWATER, FL 33762 | No data |
| CHANGE OF MAILING ADDRESS | 2006-04-21 | 3350 ULMERTON ROAD, SUITE 16, CLEARWATER, FL 33762 | No data |
| REGISTERED AGENT NAME CHANGED | 2001-10-15 | LEVERING, PAMELA A | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2014-04-28 |
| ANNUAL REPORT | 2013-03-27 |
| ANNUAL REPORT | 2012-01-19 |
| ANNUAL REPORT | 2011-06-22 |
| ANNUAL REPORT | 2010-02-12 |
| ANNUAL REPORT | 2009-04-08 |
| ANNUAL REPORT | 2008-03-31 |
| ANNUAL REPORT | 2007-03-26 |
| ANNUAL REPORT | 2006-04-21 |
| ANNUAL REPORT | 2005-05-03 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
