| Entity Name: | PROVITA PHYSICIAN GROUP CORP |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 17 Mar 2022 (3 years ago) |
| Document Number: | P22000020388 |
| FEI/EIN Number | 88-1297728 |
| Address: | 3157 N University Dr., Suite 103, Davie, FL 33024 |
| Mail Address: | 16325 NW 11TH ST, PEMBROKE PINES, FL 33028 |
| ZIP code: | 33024 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1992435622 | 2022-06-15 | 2023-03-07 | 3157 N UNIVERSITY DR STE 103, HOLLYWOOD, FL, 330242258, US | 3157 N UNIVERSITY DR STE 103, HOLLYWOOD, FL, 330242258, US | |||||||||||||||||||||||||||
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| Phone | +1 954-322-8985 |
| Fax | 9543228981 |
Authorized person
| Name | ILEANA DELGADO |
| Role | OFFICE MANAGER |
| Phone | 3058789072 |
Taxonomy
| Taxonomy Code | 261Q00000X - Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | CAQH |
| Number | 15388808 |
| State | FL |
| Issuer | MEDICAL LICENSE |
| Number | APRN9243523 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PLACENCIA, OSMANI | Agent | 16325 NW 11TH ST, PEMBROKE PINES, FL 33028 |
| Name | Role | Address |
|---|---|---|
| PLACENCIA, OSMANI | President | 16325 NW 11TH ST, PEMBROKE PINES, FL 33028 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-03 | 3157 N University Dr., Suite 103, Davie, FL 33024 | No data |
| CHANGE OF MAILING ADDRESS | 2024-04-03 | 3157 N University Dr., Suite 103, Davie, FL 33024 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-03 | 16325 NW 11TH ST, PEMBROKE PINES, FL 33028 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-02-21 |
| Domestic Profit | 2022-03-17 |
Date of last update: 12 Jan 2025
Sources: Florida Department of State
