| Entity Name: | LAKE MARY PHYSICAL THERAPY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 21 Nov 1991 (33 years ago) |
| Document Number: | S95681 |
| FEI/EIN Number | 593093440 |
| Address: | 3850 SHERIDAN STREET, HOLLYWOOD, FL, 33021, US |
| Mail Address: | 3850 SHERIDAN STREET, HOLLYWOOD, FL, 33021, US |
| ZIP code: | 33021 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1316089568 | 2007-02-13 | 2020-08-22 | 820 W LAKE MARY BLVD, SUITE 102, SANFORD, FL, 327735946, US | 820 W LAKE MARY BLVD, SUITE 102, SANFORD, FL, 327735946, US | |||||||||||||||||||||||||
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| Phone | +1 407-321-6644 |
| Fax | 4073217309 |
Authorized person
| Name | MR. GARY JAMES PIACENTINE |
| Role | PRESIDENT |
| Phone | 4073216644 |
Taxonomy
| Taxonomy Code | 261QP2000X - Physical Therapy Clinic/Center |
| License Number | PT1410 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS PROVIDER NUMBER |
| Number | Y922P |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHAPIRO, CHARLES | Agent | 3850 SHERIDAN ST, HOLLYWOOD, FL, 33021 |
| Name | Role | Address |
|---|---|---|
| SHAPIRO, CHARLES | Director | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| SHAPIRO, ANNA | Director | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| PIACENTINE, GARY | Director | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| Name | Role | Address |
|---|---|---|
| SHAPIRO, ANNA | Secretary | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| Name | Role | Address |
|---|---|---|
| SHAPIRO, ANNA | Treasurer | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| Name | Role | Address |
|---|---|---|
| PIACENTINE, GARY | President | 3850 SHERIDAN ST, HOLLYWOOD, FL |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2012-09-28 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
