| Entity Name: | MYRTLE RIDGE PRIMARY CARE P.A |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 19 Mar 2020 (5 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 07 Jul 2020 (5 years ago) |
| Document Number: | P20000024973 |
| FEI/EIN Number | 85-0505872 |
| Address: | 1539 DALE MABRY HWY, SUIT #102, LUTZ, FL, AL, 33548, US |
| Mail Address: | 1539 DALE MABRY HWY, SUIT #102, LUTZ, FL, AL, 33548, US |
| ZIP code: | 33548 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1700553633 | 2021-08-27 | 2024-05-06 | 1539 DALE MABRY HWY STE 102, LUTZ, FL, 335483008, US | 1539 DALE MABRY HWY STE 102, LUTZ, FL, 335483008, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 813-909-7102 |
| Fax | 8139090199 |
Authorized person
| Name | YUDAISY MOGENA |
| Role | OFFICE MANAGER |
| Phone | 8139097102 |
Taxonomy
| Taxonomy Code | 251B00000X - Case Management Agency |
| Is Primary | Yes |
| Taxonomy Code | 261QC1500X - Community Health Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 111603900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MOGENA YUDAISY | Agent | 10618 DEERBERRY DR, LAND O LAKES, FL, 34638 |
| Name | Role | Address |
|---|---|---|
| TORRES PEREZ WILLIAM | President | 7403 MILESTONE DR, APOLLO BEACH, FL, 33572 |
| Name | Role | Address |
|---|---|---|
| MOGENA YUDAISY | Authorized Member | 10618 DEERBERRY DR, LAND O LAKES, FL, 34638 |
| DORTA GEORGE M | Authorized Member | 10618 DEERBERRY DR, LAND O LAKES, FL, 34638 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-04-03 | MOGENA, YUDAISY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-03 | 10618 DEERBERRY DR, LAND O LAKES, FL 34638 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-04-30 | 1539 DALE MABRY HWY, SUIT #102, LUTZ, FL, AL 33548 | No data |
| CHANGE OF MAILING ADDRESS | 2021-04-30 | 1539 DALE MABRY HWY, SUIT #102, LUTZ, FL, AL 33548 | No data |
| AMENDMENT | 2020-07-07 | No data | No data |
| NAME CHANGE AMENDMENT | 2020-05-04 | MYRTLE RIDGE PRIMARY CARE P.A | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-04-04 |
| ANNUAL REPORT | 2022-04-28 |
| ANNUAL REPORT | 2021-04-30 |
| Amendment | 2020-07-07 |
| Name Change | 2020-05-04 |
| Domestic Profit | 2020-03-19 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
