| Entity Name: | PREMIER INTERVENTIONAL & DIAGNOSTIC RADIOLOGY CORP. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 18 Nov 2016 (8 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 01 Nov 2022 (2 years ago) |
| Document Number: | P16000092916 |
| FEI/EIN Number | 81-4498774 |
| Address: | 7556 LAKE WORTH RD, SUITE 102, LAKE WORTH, FL 33467 |
| Mail Address: | 7556 LAKE WORTH RD, SUITE 102, LAKE WORTH, FL 33467 |
| ZIP code: | 33467 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1801437041 | 2019-09-30 | 2024-04-10 | 7556 LAKE WORTH RD STE 103, LAKE WORTH, FL, 334672503, US | 7556 LAKE WORTH RD STE 103, LAKE WORTH, FL, 334672503, US | |||||||||||||||||||||
|
|||||||||||||||||||||||||
| Phone | +1 561-894-1370 |
| Fax | 5618941372 |
Authorized person
| Name | DR. EMILIO LOPEZ |
| Role | AUTHORIZED OFFICIAL/OWNER |
| Phone | 7865477655 |
Taxonomy
| Taxonomy Code | 2085R0204X - Vascular & Interventional Radiology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 104439200 |
| State | FL |
| Name | Role |
|---|---|
| VALEZAR & ASSOCIATES, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| LOPEZ, EMILIO | President | 8495 SW 56 Street, Miami, FL 33155 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000145017 | PREMIER VASCULAR AND INTERVENTIONAL | ACTIVE | 2020-11-11 | 2025-12-31 | No data | 7556 LAKE WORTH RD SUITE 103, LAKE WORTH, FL, 33467 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-01-16 | 7556 LAKE WORTH RD, SUITE 102, LAKE WORTH, FL 33467 | No data |
| CHANGE OF MAILING ADDRESS | 2024-01-16 | 7556 LAKE WORTH RD, SUITE 102, LAKE WORTH, FL 33467 | No data |
| AMENDMENT | 2022-11-01 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-16 |
| ANNUAL REPORT | 2023-01-20 |
| Amendment | 2022-11-01 |
| ANNUAL REPORT | 2022-04-11 |
| ANNUAL REPORT | 2021-07-27 |
| ANNUAL REPORT | 2020-03-22 |
| ANNUAL REPORT | 2019-04-23 |
| ANNUAL REPORT | 2018-04-30 |
| ANNUAL REPORT | 2017-04-05 |
| Domestic Profit | 2016-11-18 |
Date of last update: 19 Jan 2025
Sources: Florida Department of State
