| Entity Name: | LAKE NEUROLOGY CLINIC, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 10 Jun 2002 (23 years ago) |
| Date of dissolution: | 22 Sep 2017 (7 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 22 Sep 2017 (7 years ago) |
| Document Number: | P02000064029 |
| FEI/EIN Number | 030462195 |
| Address: | 608 A S. 9TH STREET, LEESBURG, FL, 34748 |
| Mail Address: | P.O. BOX 490123, LEESBURG, FL, 34749 |
| ZIP code: | 34748 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1700958600 | 2006-11-15 | 2010-03-05 | PO BOX 490123, LEESBURG, FL, 347490123, US | 608 S 9TH STREET, STE A, LEESBURG, FL, 34748, US | |||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||
| Phone | +1 352-360-1122 |
| Fax | 3523601123 |
Authorized person
| Name | MARILYN C GLOVER |
| Role | OFFICE MANAGER |
| Phone | 3523601122 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME76490 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE RAILROAD |
| Number | 130025175 |
| State | FL |
| Issuer | BCBS |
| Number | 44751 |
| State | FL |
| Issuer | MEDICAID |
| Number | 257303200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JOHNSON CHARLES D | Agent | 907 WEBSTER STREET, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| PATTERSON-LAKE MARLYN A | President | 608 A S. 9TH STREET, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| PATTERSON-LAKE MARLYN A | Secretary | 608 A S. 9TH STREET, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| PATTERSON-LAKE MARLYN A | Treasurer | 608 A S. 9TH STREET, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| PATTERSON-LAKE MARLYN A | Director | 608 A S. 9TH STREET, LEESBURG, FL, 34748 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-03-28 | JOHNSON, CHARLES D | No data |
| REINSTATEMENT | 2016-03-28 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2012-09-28 | No data | No data |
| REINSTATEMENT | 2011-10-04 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2011-09-23 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2010-04-30 | 608 A S. 9TH STREET, LEESBURG, FL 34748 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2008-07-29 | 608 A S. 9TH STREET, LEESBURG, FL 34748 | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2016-03-28 |
| REINSTATEMENT | 2011-10-04 |
| ANNUAL REPORT | 2010-04-30 |
| ANNUAL REPORT | 2009-02-15 |
| ANNUAL REPORT | 2008-07-29 |
| ANNUAL REPORT | 2007-04-10 |
| ANNUAL REPORT | 2006-02-03 |
| ANNUAL REPORT | 2005-01-31 |
| ANNUAL REPORT | 2004-04-04 |
| ANNUAL REPORT | 2003-04-18 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
