| Entity Name: | GULF COAST RETINA ASSOCIATES, L.L.C. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 25 Jun 2003 (22 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 28 Oct 2024 (4 months ago) |
| Document Number: | L03000023082 |
| FEI/EIN Number | 412104593 |
| Address: | 232 Rue des Lacs, Tarpon Springs, FL, 34688, US |
| Mail Address: | 232 Rue des Lacs, Tarpon Springs, FL, 34688, US |
| ZIP code: | 34688 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1780724112 | 2007-02-07 | 2018-11-02 | 2055 LITTLE RD, TRINITY, FL, 346554421, US | 2055 LITTLE RD, TRINITY, FL, 34655, US | |||||||||||||||||||||||||
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| Phone | +1 727-862-3090 |
| Fax | 7278623023 |
Authorized person
| Name | MR. DOUG DAVIS |
| Role | OFFICE MANAGER |
| Phone | 7278623090 |
Taxonomy
| Taxonomy Code | 207WX0107X - Retina Specialist (Ophthalmology) Physician |
| License Number | ME68907 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 379522500 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| GULF COAST RETINA ASSOCIATES, LLC | 2020 | 412104593 | 2022-04-08 | GULF COAST RETINA ASSOCIATES | 5 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2022-04-08 |
| Name of individual signing | BRENT MONTZKA |
| Valid signature | Filed with authorized/valid electronic signature |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2004-01-01 |
| Business code | 621320 |
| Sponsor’s telephone number | 7278623090 |
| Plan sponsor’s address | 2055 LITTLE ROAD, TRINITY, FL, 34655 |
Signature of
| Role | Plan administrator |
| Date | 2021-12-16 |
| Name of individual signing | BRENT MONTZKA |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2004-01-01 |
| Business code | 621320 |
| Sponsor’s telephone number | 7278623090 |
| Plan sponsor’s address | 2055 LITTLE ROAD, TRINITY, FL, 34655 |
Signature of
| Role | Plan administrator |
| Date | 2020-06-17 |
| Name of individual signing | DOUG DAVIS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2004-01-01 |
| Business code | 621320 |
| Sponsor’s telephone number | 7278623090 |
| Plan sponsor’s address | 2055 LITTLE ROAD, TRINITY, FL, 34655 |
Signature of
| Role | Plan administrator |
| Date | 2020-06-05 |
| Name of individual signing | DOUGLAS M DAVIS |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Montzka Dan P | Sole | 232 Rue des Lacs, Tarpon Springs, FL, 34688 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-10-28 | 232 Rue des Lacs, Tarpon Springs, FL 34688 | No data |
| CHANGE OF MAILING ADDRESS | 2024-10-28 | 232 Rue des Lacs, Tarpon Springs, FL 34688 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-10-28 | C T CORPORATION SYSTEM | No data |
| REINSTATEMENT | 2024-10-28 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-07-12 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| LC STMNT OF RA/RO CHG | 2024-07-12 | No data | No data |
| LC STMNT OF RA/RO CHG | 2018-12-19 | No data | No data |
| NAME CHANGE AMENDMENT | 2003-08-26 | GULF COAST RETINA ASSOCIATES, L.L.C. | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-10-28 |
| CORLCRACHG | 2024-07-12 |
| ANNUAL REPORT | 2023-04-24 |
| ANNUAL REPORT | 2022-01-06 |
| AMENDED ANNUAL REPORT | 2021-11-09 |
| ANNUAL REPORT | 2021-03-03 |
| ANNUAL REPORT | 2020-01-27 |
| ANNUAL REPORT | 2019-02-11 |
| CORLCRACHG | 2018-12-19 |
| ANNUAL REPORT | 2018-01-10 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
