| Entity Name: | INTERMED OF BOCA RATON, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 09 Jan 2003 (22 years ago) |
| Document Number: | P03000004266 |
| FEI/EIN Number | 141867975 |
| Address: | 950 GLADES ROAD, Boca Raton, FL, 33432, US |
| Mail Address: | 4855 W. HILLSBORO BLVD. SUITE B-2, COCONUT CREEK, FL, 33073, US |
| ZIP code: | 33432 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407212327 | 2016-01-07 | 2021-07-12 | 4855 W HILLSBORO BLVD, SUITE B2, COCONUT CREEK, FL, 330734356, US | 950 GLADES RD STE 4D, BOCA RATON, FL, 334316401, US | |||||||||||||||||||||||||||||||
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| Phone | +1 954-418-1683 |
| Fax | 9543548151 |
| Phone | +1 561-391-8086 |
Authorized person
| Name | CHANTAL BRAY |
| Role | CEO |
| Phone | 9542547968 |
Taxonomy
| Taxonomy Code | 207K00000X - Allergy & Immunology Physician |
| Is Primary | Yes |
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICARE |
| Number | 74563 |
| State | FL |
| Name | Role |
|---|---|
| INTERMED OF BOCA RATON, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| BRAY CHANTAL | Director | 4855 W. HILLSBORO BLVD. SUITE B-2, COCONUT CREEK, FL, 33073 |
| BOURQUE LISE | Director | 4855 W. HILLSBORO BLVD. SUITE B-2, COCONUT CREEK, FL, 33073 |
| Name | Role | Address |
|---|---|---|
| Bray Sophie | Chief Financial Officer | 4855 W. HILLSBORO BLVD. SUITE B-2, COCONUT CREEK, FL, 33073 |
| Name | Role | Address |
|---|---|---|
| Hutchison Michael | Secretary | 4855 W hillsboro Blvd, Coconut Creek, FL, 33073 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2015-10-26 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
