| Entity Name: | ROBERTA A. MIX, D.O., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 03 May 1999 (26 years ago) |
| Date of dissolution: | 25 Sep 2015 (9 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2015 (9 years ago) |
| Document Number: | P99000040615 |
| FEI/EIN Number | 593585245 |
| Address: | 2102 TRINITY OAKS BLVD, STE 201, NEW PORT RICHEY, FL, 34655 |
| Mail Address: | 5117 JEWELL TERRACE, PALM HARBOR, FL, 34685 |
| ZIP code: | 34655 |
| County: | Pasco |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1831282110 | 2006-10-01 | 2012-11-26 | 2102 TRINITY OAKS BLVD, SUITE 201, TRINITY, FL, 346554409, US | 2102 TRINITY OAKS BLVD, SUITE 201, TRINITY, FL, 346554409, US | |||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||
| Phone | +1 727-376-8885 |
| Fax | 7273767997 |
Authorized person
| Name | DR. ROBERTA ANN MIX |
| Role | PRESIDENT |
| Phone | 7273768885 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | OS7532 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2563461-00 |
| State | FL |
| Issuer | DME |
| Number | 4867933001 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MIX ROBERTA A | Agent | 5117 JEWELL TERRACE, PALM HARBOR, FL, 34685 |
| Name | Role | Address |
|---|---|---|
| MIX ROBERTA A | Director | 2102 TRINITY OAKS BLVD., STE 127, NEW PORT RICHEY, FL, 34655 |
| Name | Role | Address |
|---|---|---|
| MIX ROBERTA A | President | 2102 TRINITY OAKS BLVD., STE 127, NEW PORT RICHEY, FL, 34655 |
| Name | Role | Address |
|---|---|---|
| MIX ROBERTA A | Secretary | 2102 TRINITY OAKS BLVD., STE 127, NEW PORT RICHEY, FL, 34655 |
| Name | Role | Address |
|---|---|---|
| Carson John L | Chief Financial Officer | 5117 Jewell Terrace, Palm Harbor, FL, 34685 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2015-01-20 | 2102 TRINITY OAKS BLVD, STE 201, NEW PORT RICHEY, FL 34655 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-01-20 | 5117 JEWELL TERRACE, PALM HARBOR, FL 34685 | No data |
| REGISTERED AGENT NAME CHANGED | 2015-01-20 | MIX, ROBERTA A | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2011-02-23 | 2102 TRINITY OAKS BLVD, STE 201, NEW PORT RICHEY, FL 34655 | No data |
| REINSTATEMENT | 2009-04-09 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2008-09-26 | No data | No data |
| Name | Date |
|---|---|
| Reg. Agent Change | 2015-01-20 |
| ANNUAL REPORT | 2014-03-27 |
| ANNUAL REPORT | 2013-03-21 |
| ANNUAL REPORT | 2012-04-12 |
| ANNUAL REPORT | 2011-02-23 |
| ANNUAL REPORT | 2010-04-04 |
| REINSTATEMENT | 2009-04-09 |
| ANNUAL REPORT | 2007-01-23 |
| ANNUAL REPORT | 2006-01-08 |
| ANNUAL REPORT | 2005-01-23 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
