| Entity Name: | IDA WALLACE BENNETT FAMILY HEALTH, CORPORATION. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 07 Sep 2006 (18 years ago) |
| Document Number: | P06000115836 |
| FEI/EIN Number | 651291931 |
| Address: | 5944 E COPPS HWY, LAMONT, FL, 32336 |
| Mail Address: | 742 Olympic Circle, Ocoee, FL, 34761, US |
| ZIP code: | 32336 |
| County: | Jefferson |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1417085697 | 2007-03-01 | 2013-07-16 | 331 N DEERFIELD AVENUE, DEERFIELD BEACH, FL, 334412028, US | 331 N DEERFIELD AVE, DEERFIELD BEACH, FL, 334412028, US | |||||||||||||||||||||||||||||
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| Phone | +1 561-900-6737 |
| Fax | 9544221726 |
Authorized person
| Name | PAMELA V JOHNSON |
| Role | PRESIDENT |
| Phone | 5619006737 |
Taxonomy
| Taxonomy Code | 261QH0100X - Health Service Clinic/Center |
| Is Primary | No |
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| License Number | ARNP2155102 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PTAN AK407 |
| Number | BCBSFL |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JOHNSON PAMELA V | Agent | 742 Olympic Circle, Ocoee, FL, 34761 |
| Name | Role | Address |
|---|---|---|
| JOHNSON PAMELA V | President | 331 N DEERFIELD AVENUE, DEERFIELD BEACH, FL, 33441 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000101588 | CONSULTIDANP | EXPIRED | 2012-10-17 | 2017-12-31 | No data | POST OFFICE BOX 783, DEERFIELD BEACH, FL, 33441 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-03-27 | 5944 E COPPS HWY, LAMONT, FL 32336 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-03-27 | 742 Olympic Circle, Ocoee, FL 34761 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2007-03-23 | 5944 E COPPS HWY, LAMONT, FL 32336 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-22 |
| ANNUAL REPORT | 2024-03-27 |
| ANNUAL REPORT | 2023-03-02 |
| ANNUAL REPORT | 2022-03-06 |
| ANNUAL REPORT | 2021-03-17 |
| ANNUAL REPORT | 2020-03-22 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-02-26 |
| ANNUAL REPORT | 2017-01-29 |
| ANNUAL REPORT | 2016-03-27 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
