| Entity Name: | ACUTE CARE PEDIATRICS OF PALM COAST, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 28 Jul 2004 (21 years ago) |
| Last Event: | AMENDMENT AND NAME CHANGE |
| Event Date Filed: | 06 Jan 2006 (19 years ago) |
| Document Number: | P04000110898 |
| FEI/EIN Number | 020728089 |
| Mail Address: | 1859 SW Newland Way, Lake City, FL, 32025, US |
| Address: | 397 SW PALM COAST PARKWAY -, UNIT 302- 303, PALM COAST, FL, 32137 |
| ZIP code: | 32137 |
| County: | Flagler |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225065717 | 2006-06-28 | 2023-07-31 | 397 PALM COAST PARKWAY SW, UNIT 303, PALM COAST, FL, 32137, US | 397 PALM COAST PARKWAY SW, UNIT 303, PALM COAST, FL, 32137, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 386-447-7337 |
| Fax | 3864477348 |
Authorized person
| Name | MRS. CHRISTINE TIU |
| Role | OFFICE MANAGER |
| Phone | 3864477337 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME 0075674 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD OF FLORIDA |
| Number | 009US |
| State | FL |
| Issuer | MEDICAID |
| Number | 000387200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Marcelino, Amie | Agent | 1859 SW Newland Way, Lake City, FL, 32025 |
| Name | Role | Address |
|---|---|---|
| SANTELICES SAMUEL M | Manager | 8652 SW 42nd Place, Gainesville, FL, 32608 |
| Tiu Christine | Manager | 12 Floyd Ct, Palm Coast, FL, 32137 |
| Name | Role | Address |
|---|---|---|
| SANTELICES SAMUEL M | Director | 8652 SW 42nd Place, Gainesville, FL, 32608 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-05-03 | 397 SW PALM COAST PARKWAY -, UNIT 302- 303, PALM COAST, FL 32137 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-05-03 | 1859 SW Newland Way, Lake City, FL 32025 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-05-03 | Marcelino, Amie | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-01-07 | 397 SW PALM COAST PARKWAY -, UNIT 302- 303, PALM COAST, FL 32137 | No data |
| AMENDMENT AND NAME CHANGE | 2006-01-06 | ACUTE CARE PEDIATRICS OF PALM COAST, PA | No data |
| CANCEL ADM DISS/REV | 2005-12-01 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| NAME CHANGE AMENDMENT | 2004-11-10 | ACUTE CARE PEDIATRICS OF JACKSONVILLE, PA | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-15 |
| AMENDED ANNUAL REPORT | 2024-05-03 |
| AMENDED ANNUAL REPORT | 2024-03-20 |
| ANNUAL REPORT | 2024-02-26 |
| ANNUAL REPORT | 2023-02-05 |
| ANNUAL REPORT | 2022-01-17 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-01-11 |
| ANNUAL REPORT | 2019-03-01 |
| ANNUAL REPORT | 2018-03-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
