| Entity Name: | LA CLINIQUE 300, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 01 Jul 2015 (10 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 28 Sep 2021 (3 years ago) |
| Document Number: | P15000056939 |
| FEI/EIN Number | 65-0167934 |
| Address: | 2630 N. ANDREWS AVENUE, WILTON MANORS, FL 33311 |
| Mail Address: | 2630 N. ANDREWS AVENUE, WILTON MANORS, FL 33311 |
| ZIP code: | 33311 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1689059453 | 2015-07-22 | 2016-05-09 | 2630 N ANDREWS AVE, WILTON MANORS, FL, 333112550, US | 2630 N ANDREWS AVE, WILTON MANORS, FL, 333112550, US | |||||||||||||||||||||||||
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| Phone | +1 954-525-4900 |
| Fax | 9543963110 |
Authorized person
| Name | DR. JOSEPH FANFAN |
| Role | PRESIDENT |
| Phone | 9545254900 |
Taxonomy
| Taxonomy Code | 261Q00000X - Clinic/Center |
| License Number | ME43065 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 068166100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FANFAN, JOSEPH, JR | Agent | 2630 N. ANDREWS AVENUE, WILTON MANORS, FL 33311 |
| Name | Role | Address |
|---|---|---|
| FANFAN, JOSEPH, JR., MD | President | 2630 N. ANDREWS AVENUE, WILTON MANOR, FL 33311 |
| Name | Role | Address |
|---|---|---|
| FANFAN, KETLYNE | Executive Vice President | 2630 N. ANDREWS AVENUE, WILTON MANORS, FL 33311 |
| Name | Role | Address |
|---|---|---|
| FANFAN, JOSEPH, JR. | CB | 2630 N. ANDREWS AVENUE, WILTON MANORS, FL 33311 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000058652 | JOSEPH FANFAN JR MD PA | EXPIRED | 2016-06-14 | 2021-12-31 | No data | 2630 N ANDREWS AVENUE, WILTON MANORS, FL, 33311 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2021-09-28 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2021-09-28 | FANFAN, JOSEPH, JR | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-03-21 |
| ANNUAL REPORT | 2022-02-28 |
| REINSTATEMENT | 2021-09-28 |
| ANNUAL REPORT | 2020-03-03 |
| ANNUAL REPORT | 2019-02-20 |
| ANNUAL REPORT | 2018-01-16 |
| ANNUAL REPORT | 2017-04-18 |
| ANNUAL REPORT | 2016-04-07 |
| Domestic Profit | 2015-07-01 |
Date of last update: 20 Jan 2025
Sources: Florida Department of State
