| Entity Name: | NORTH LAKE PRIMARY CARE, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 04 Nov 2014 (10 years ago) |
| Date of dissolution: | 28 Sep 2018 (6 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 28 Sep 2018 (6 years ago) |
| Document Number: | P14000090067 |
| FEI/EIN Number | 47-2271903 |
| Address: | 6 N. Eustis Street, Eustis, FL, 32726, US |
| Mail Address: | 6 N. Eustis Street, Eustis, FL, 32726, US |
| ZIP code: | 32726 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1962809145 | 2014-12-03 | 2014-12-03 | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 327579134, US | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 327579134, US | |||||||||||||||||||||||
|
|||||||||||||||||||||||||||
| Phone | +1 352-516-8931 |
Authorized person
| Name | MR. JEREMY E. CREECH |
| Role | PROPRIETOR |
| Phone | 3525168931 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | 363L00000X |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 009259700 |
| State | FL |
| Name | Role |
|---|---|
| UNITED STATES CORPORATION AGENTS, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| CREECH JEREMY E | President | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 32757 |
| Name | Role | Address |
|---|---|---|
| CREECH JEREMY E | Secretary | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 32757 |
| Name | Role | Address |
|---|---|---|
| CREECH JEREMY E | Treasurer | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 32757 |
| Name | Role | Address |
|---|---|---|
| CREECH JEREMY E | Director | 8022 SAINT JAMES WAY, MOUNT DORA, FL, 32757 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2023-02-06 | 476 RIVERSIDE AVE., JACKSONVILLE, FL 32202 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2017-01-21 | 6 N. Eustis Street, Eustis, FL 32726 | No data |
| REGISTERED AGENT NAME CHANGED | 2017-01-21 | UNITED STATES CORPORATION AGENTS, INC. | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2017-01-21 | 6 N. Eustis Street, Eustis, FL 32726 | No data |
| REINSTATEMENT | 2017-01-21 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2017-01-21 |
| Domestic Profit | 2014-11-04 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
