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  5. ATLANTIC DERMATOLOGY LLC

ATLANTIC DERMATOLOGY LLC

Company Details

Entity Name: ATLANTIC DERMATOLOGY LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 06 Jan 2005 (20 years ago)
Document Number: L05000001644
FEI/EIN Number 202111643
Address: 1980 N. ATLANTIC AVE., SUITE 722, COCOA BEACH, FL, 32931, US
Mail Address: 1980 N. ATLANTIC AVE., SUITE 722, COCOA BEACH, FL, 32931, US
ZIP code: 32931
County: Brevard
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1306957378 2006-08-31 2020-08-22 1980 N ATLANTIC AVE, SUITE 722, COCOA BEACH, FL, 329315213, US 1980 N ATLANTIC AVE, SUITE 722, COCOA BEACH, FL, 329315213, US

Contacts
Phone +1 321-784-8811
Fax 3217994424

Authorized person
Name MRS. KRISTIN WIDICK SMALLWOOD
Role PRESIDENT
Phone 3217848811

Taxonomy
Taxonomy Code 207N00000X - Dermatology Physician
Is Primary No
Taxonomy Code 207NI0002X - Clinical & Laboratory Dermatological Immunology Physician
Is Primary No
Taxonomy Code 207NP0225X - Pediatric Dermatology Physician
Is Primary No
Taxonomy Code 207NS0135X - Procedural Dermatology Physician
Is Primary No

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2015 202111643 2016-05-13 ATLANTIC DERMATOLOGY, LLC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2014 202111643 2015-10-05 ATLANTIC DERMATOLOGY, LLC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2013 202111643 2014-07-11 ATLANTIC DERMATOLOGY, LLC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2012 202111643 2013-07-02 ATLANTIC DERMATOLOGY, LLC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931

Signature of
Role Plan administrator
Date 2013-07-02
Name of individual signing TATIANA POMBO
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2013-07-02
Name of individual signing TATIANA POMBO
Valid signature Filed with authorized/valid electronic signature
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2011 202111643 2012-04-13 ATLANTIC DERMATOLOGY, LLC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931

Plan administrator’s name and address
Administrator’s EIN 202111643
Plan administrator’s name ATLANTIC DERMATOLOGY, LLC
Plan administrator’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
Administrator’s telephone number 3217848811

Signature of
Role Plan administrator
Date 2012-04-13
Name of individual signing TATIANA POMBO
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2012-04-13
Name of individual signing TATIANA POMBO
Valid signature Filed with authorized/valid electronic signature
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2010 202111643 2011-06-16 ATLANTIC DERMATOLOGY, LLC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931

Plan administrator’s name and address
Administrator’s EIN 202111643
Plan administrator’s name ATLANTIC DERMATOLOGY, LLC
Plan administrator’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
Administrator’s telephone number 3217848811

Signature of
Role Plan administrator
Date 2011-06-16
Name of individual signing TATIANA CHAVEZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-06-16
Name of individual signing TATIANA CHAVEZ
Valid signature Filed with authorized/valid electronic signature
ATLANTIC DERMATOLOGY, LLC PROFIT SHARING PLAN 2009 202111643 2010-09-21 ATLANTIC DERMATOLOGY, LLC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3217848811
Plan sponsor’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931

Plan administrator’s name and address
Administrator’s EIN 202111643
Plan administrator’s name ATLANTIC DERMATOLOGY, LLC
Plan administrator’s address 1980 N. ATLANTIC AVENUE, STE 722, COCOA BEACH, FL, 32931
Administrator’s telephone number 3217848811

Signature of
Role Plan administrator
Date 2010-09-21
Name of individual signing JULIE BURGESS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
SMALLWOOD KRISTIN W Agent 56 CRYSTAL RIVER DR, COCOA BEACH, FL, 32931

Manager

Name Role Address
SMALLWOOD KRISTIN W Manager 56 CRYSTAL RIVER, COCOA BEACH, FL, 32931

Events

Event Type Filed Date Value Description
REGISTERED AGENT ADDRESS CHANGED 2025-01-07 56 CRYSTAL RIVER DR, COCOA BEACH, FL 32931 No data
REGISTERED AGENT ADDRESS CHANGED 2008-01-08 56 CRYSTAL RIVER, COCOA BEACH, FL 32931 No data
CHANGE OF PRINCIPAL ADDRESS 2005-08-18 1980 N. ATLANTIC AVE., SUITE 722, COCOA BEACH, FL 32931 No data
CHANGE OF MAILING ADDRESS 2005-08-18 1980 N. ATLANTIC AVE., SUITE 722, COCOA BEACH, FL 32931 No data

Documents

Name Date
ANNUAL REPORT 2025-01-07
ANNUAL REPORT 2024-01-03
ANNUAL REPORT 2023-01-03
ANNUAL REPORT 2022-01-05
ANNUAL REPORT 2021-01-11
ANNUAL REPORT 2020-01-15
ANNUAL REPORT 2019-01-10
ANNUAL REPORT 2018-01-15
ANNUAL REPORT 2017-01-06
ANNUAL REPORT 2016-01-11

Related by officers

SMALLWOOD KRISTIN W

K&C TIMBER LLC

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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