| Entity Name: | HEARTLAND PEDIATRICS OF LAKE PLACID, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 12 Jan 1998 (27 years ago) |
| Document Number: | P98000003974 |
| FEI/EIN Number | 593488365 |
| Address: | 344 E. ROYAL PALM ST., STE 3, LAKE PLACID, FL, 33852, US |
| Mail Address: | 1354 STATE ROAD 60 EAST, LAKE WALES, FL, 33853, US |
| ZIP code: | 33852 |
| County: | Highlands |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1265453203 | 2006-07-23 | 2011-05-09 | 344 E ROYAL PALM ST, SUITE # 3, LAKE PLACID, FL, 338525020, US | 344 E ROYAL PALM ST, SUITE # 3, LAKE PLACID, FL, 338525020, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 863-699-1414 |
| Fax | 8636999790 |
Authorized person
| Name | DR. RAJESWARI SONNI |
| Role | PRESIDENT/ MEDICAL DIRECTOR |
| Phone | 8636991414 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 253535100 |
| State | FL |
| Issuer | MEDICAID |
| Number | 253535101 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELD OF FLORIDA |
| Number | 21799 |
| State | FL |
| Name | Role |
|---|---|
| DEAN MEAD SERVICES, LLC | Agent |
| Name | Role | Address |
|---|---|---|
| SONNI RAJESWARI M | President | 344 E. ROYAL PALM STREET, SUITE 3, LAKE PLACID, FL, 33852 |
| Name | Role | Address |
|---|---|---|
| HREN LAURENCE | Administrator | 1354 STATE ROAD 60 EAST, LAKE WALES, FL, 33853 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| RESTATED ARTICLES | 2011-02-16 | No data | No data |
| RESTATED ARTICLES AND NAME CHANGE | 2011-02-16 | HEARTLAND PEDIATRICS OF LAKE PLACID, INC. | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
