| Entity Name: | KIDSVILLE PEDIATRICS IV, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 18 Oct 2005 (19 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 05 Jul 2011 (14 years ago) |
| Document Number: | P05000142184 |
| FEI/EIN Number | 13-4311321 |
| Mail Address: | P.O. BOX 452223, KISSIMMEE, FL 34745 |
| Address: | 11886 LAKE UNDERHILL RD., ORLANDO, FL 32825 |
| ZIP code: | 32825 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1508955212 | 2006-10-12 | 2019-08-13 | 11886 LAKE UNDERHILL RD, ORLANDO, FL, 328254436, US | 11886 LAKE UNDERHILL RD, ORLANDO, FL, 328254436, US | |||||||||||||||||||||||||
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| Phone | +1 407-447-7773 |
| Fax | 4074477804 |
Authorized person
| Name | DR. FRANCELIS I. GONZALEZ |
| Role | CEO |
| Phone | 4074477773 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME-0074421 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 274349300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PANTOJA, VICTOR M, Jr. | Agent | 11886 Lake UnderHill RD, ORLANDO, FL 32825 |
| Name | Role | Address |
|---|---|---|
| GONZALEZ, FRANCELIS I, MD | Chief Executive Officer | P.O. BOX 452223, KISSIMMEE, FL 34745 |
| Name | Role | Address |
|---|---|---|
| PANTOJA, VICTOR M., Jr. | President | P.O. BOX 452223, KISSIMMEE, FL 34745 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2019-02-09 | 11886 Lake UnderHill RD, ORLANDO, FL 32825 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2013-03-03 | 11886 LAKE UNDERHILL RD., ORLANDO, FL 32825 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-03-03 | PANTOJA, VICTOR M, Jr. | No data |
| AMENDMENT | 2011-07-05 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2008-03-17 | 11886 LAKE UNDERHILL RD., ORLANDO, FL 32825 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-04 |
| ANNUAL REPORT | 2023-02-17 |
| ANNUAL REPORT | 2022-02-22 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-02-17 |
| ANNUAL REPORT | 2019-02-09 |
| ANNUAL REPORT | 2018-03-10 |
| ANNUAL REPORT | 2017-02-09 |
| AMENDED ANNUAL REPORT | 2016-05-31 |
| ANNUAL REPORT | 2016-03-04 |
Date of last update: 28 Jan 2025
Sources: Florida Department of State
