| Entity Name: | PAIN RELIEF AND PHYSICAL REHAB, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 26 Aug 2008 (16 years ago) |
| Document Number: | P08000079339 |
| FEI/EIN Number | 263254428 |
| Address: | 4977 ROYAL GULF CIR., FORT MYERS, FL, 33966, US |
| Mail Address: | P. O. BOX 222, ESTERO, FL, 33929, US |
| ZIP code: | 33966 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1134378938 | 2008-09-17 | 2023-09-26 | 9705 COMMERCE CENTER CT STE 103, FORT MYERS, FL, 339083767, US | 4977 ROYAL GULF CIR, FORT MYERS, FL, 339667006, US | |||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 239-437-9313 |
| Fax | 2392458060 |
| Phone | +1 239-226-0077 |
| Fax | 2394890077 |
Authorized person
| Name | DR. KEITH S SUSKO |
| Role | PRESIDENT |
| Phone | 2392260077 |
Taxonomy
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| Is Primary | Yes |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 17033 |
| State | FL |
| Issuer | MEDICAID |
| Number | 2658666-00 |
| State | FL |
| Issuer | MEDICARE |
| Number | 17033X |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SUSKO KEITH | Agent | 4977 ROYAL GULF CIR., FORT MYERS, FL, 33966 |
| Name | Role | Address |
|---|---|---|
| SUSKO KEITH | President | P. O. BOX 222, ESTERO, FL, 33929 |
| Name | Role | Address |
|---|---|---|
| SUSKO KEITH | Secretary | P. O. BOX 222, ESTERO, FL, 33929 |
| Name | Role | Address |
|---|---|---|
| SUSKO KEITH | Treasurer | P. O. BOX 222, ESTERO, FL, 33929 |
| Name | Role | Address |
|---|---|---|
| SUSKO KEITH | Director | P. O. BOX 222, ESTERO, FL, 33929 |
| JENNER TARA R | Director | P. O. BOX 222, ESTERO, FL, 33929 |
| Name | Role | Address |
|---|---|---|
| JENNER TARA R | Vice President | P. O. BOX 222, ESTERO, FL, 33929 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G19000029601 | IDEAL WEIGHT AND WELLNESS | EXPIRED | 2019-03-04 | 2024-12-31 | No data | P.O. BOX 222, ESTERO, FL, 33929 |
| G08329900037 | IDEAL WEIGHT AND WELLNESS | EXPIRED | 2008-11-19 | 2013-12-31 | No data | 12734 KENWOOD LN, #96, FORT MYERS, FL, 33907 |
| G08241900361 | PAIN RELIEF AND PHYSICAL REHAB | EXPIRED | 2008-08-28 | 2013-12-31 | No data | 12734 KENWOOD LN, #96, FORT MYERS, FL, 33907 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2019-04-19 | 4977 ROYAL GULF CIR., FORT MYERS, FL 33966 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-07-31 | 4977 ROYAL GULF CIR., FORT MYERS, FL 33966 | No data |
| CHANGE OF MAILING ADDRESS | 2010-04-22 | 4977 ROYAL GULF CIR., FORT MYERS, FL 33966 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-29 |
| ANNUAL REPORT | 2023-04-12 |
| ANNUAL REPORT | 2022-08-14 |
| ANNUAL REPORT | 2021-09-22 |
| ANNUAL REPORT | 2020-05-25 |
| ANNUAL REPORT | 2019-04-19 |
| ANNUAL REPORT | 2018-04-25 |
| ANNUAL REPORT | 2017-04-28 |
| ANNUAL REPORT | 2016-04-01 |
| ANNUAL REPORT | 2015-04-28 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
