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  5. SAND LAKE SURGICENTER, LLC

SAND LAKE SURGICENTER, LLC

Company Details

Entity Name: SAND LAKE SURGICENTER, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 14 Oct 2010 (14 years ago)
Document Number: L10000107507
FEI/EIN Number 27-3787593
Address: 7477 Sand Lake Commons Boulevard, Orlando, FL, 32819, US
Mail Address: 7477 Sand Lake Commons Boulevard, Orlando, FL, 32819, US
ZIP code: 32819
County: Orange
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1336445873 2011-02-01 2011-10-05 7477 SANDLAKE COMMONS BLVD, ORLANDO, FL, 328198034, US 7477 SANDLAKE COMMONS BLVD, ORLANDO, FL, 328198034, US

Contacts
Phone +1 407-264-9633
Fax 4072649959

Authorized person
Name MS. CHERYL MODICA
Role ADMINISTRATOR
Phone 4072649633

Taxonomy
Taxonomy Code 261QA1903X - Ambulatory Surgical Clinic/Center
License Number 1289
State FL
Is Primary Yes

Central Index Key

CIK number Mailing Address Business Address Phone
1699232 569 BROOKWOOD VILLAGE, SUITE 901, BIRMINGHAM, AL, 35209 569 BROOKWOOD VILLAGE, SUITE 901, BIRMINGHAM, AL, 35209 205-545-2734

Filings since 2019-08-13
Form type D
File number 021-346417
Filing date 2019-08-13
File View File

Filings since 2019-03-05
Form type D
File number 021-334113
Filing date 2019-03-05
File View File

Filings since 2017-03-31
Form type D
File number 021-283840
Filing date 2017-03-31
File View File

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SAND LAKE SURGICENTER, LLC 401(K) PROFIT SHARING PLAN & TRUST 2016 273787593 2018-10-09 SAND LAKE SURGICENTER, LLC 24
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Plan sponsor’s DBA name SAND LAKE SURGERY CENTER
Plan sponsor’s address 7477 SANDLAKE COMMONS BLVD, ORLANDO, FL, 328198034

Signature of
Role Plan administrator
Date 2018-10-09
Name of individual signing BARBARA TIDWELL
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-10-09
Name of individual signing BARBARA TIDWELL
Valid signature Filed with authorized/valid electronic signature
SAND LAKE SURGICENTER, LLC 401 (K) PROFIT SHARING PLAN & TURST 2015 273787593 2017-10-12 SAND LAKE SURGICENTER LLC 29
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SANDLAKE COMMONS BLVD, ORLANDO, FL, 328198034

Signature of
Role Plan administrator
Date 2017-10-12
Name of individual signing BARBARA TIDWELL
Valid signature Filed with authorized/valid electronic signature
SAND LAKE SURGICENTER,LLC 2014 273787593 2015-07-30 SAND LAKE SURGICENTER, LLC 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819

Signature of
Role Plan administrator
Date 2015-07-30
Name of individual signing CHERYL MODICA
Valid signature Filed with authorized/valid electronic signature
SAND LAKE SURGICENTER LLC 401 K PROFIT SHARING PLAN TRUST 2013 273787593 2014-07-30 SAND LAKE SURGICENTER LLC 42
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819

Signature of
Role Plan administrator
Date 2014-07-30
Name of individual signing CHERYL MODICA
Valid signature Filed with authorized/valid electronic signature
SAND LAKE SURGICENTER LLC 401 K PROFIT SHARING PLAN TRUST 2012 273787593 2014-08-11 SAND LAKE SURGICENTER LLC 41
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819

Signature of
Role Plan administrator
Date 2014-08-11
Name of individual signing SAND LAKE SURGICENTER LLC
Valid signature Filed with authorized/valid electronic signature
SAND LAKE SURGICENTER LLC 401 K PROFIT SHARING PLAN TRUST 2011 273787593 2012-07-05 SAND LAKE SURGICENTER LLC 42
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819

Plan administrator’s name and address
Administrator’s EIN 273787593
Plan administrator’s name SAND LAKE SURGICENTER LLC
Plan administrator’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819
Administrator’s telephone number 4072649633

Signature of
Role Plan administrator
Date 2012-07-05
Name of individual signing SAND LAKE SURGICENTER LLC
Valid signature Filed with incorrect/unrecognized electronic signature
SAND LAKE SURGICENTER LLC 401 K PROFIT SHARING PLAN TRUST 2011 273787593 2012-07-09 SAND LAKE SURGICENTER LLC 42
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621510
Sponsor’s telephone number 4072649633
Plan sponsor’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819

Plan administrator’s name and address
Administrator’s EIN 273787593
Plan administrator’s name SAND LAKE SURGICENTER LLC
Plan administrator’s address 7477 SAND LAKE COMMONS BLVD, ORLANDO, FL, 32819
Administrator’s telephone number 4072649633

Signature of
Role Plan administrator
Date 2012-07-09
Name of individual signing SAND LAKE SURGICENTER LLC
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role
C T CORPORATION SYSTEM Agent

Vice President

Name Role Address
Mark Ladd W Vice President 7477 Sand Lake Commons Boulevard, Orlando, FL, 32819

Member

Name Role
SCA-SAND LAKE, LLC Member

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G10000114845 SAND LAKE SURGERY CENTER ACTIVE 2010-12-15 2025-12-31 No data 7477 SAND LAKE COMMONS BOULEVARD, ORLANDO, FL, 32819

Events

Event Type Filed Date Value Description
CHANGE OF PRINCIPAL ADDRESS 2024-03-04 7477 Sand Lake Commons Boulevard, Orlando, FL 32819 No data
CHANGE OF MAILING ADDRESS 2024-03-04 7477 Sand Lake Commons Boulevard, Orlando, FL 32819 No data
REGISTERED AGENT NAME CHANGED 2015-01-21 C T Corporation System No data
REGISTERED AGENT ADDRESS CHANGED 2015-01-21 1200 South Pine Island Road, Plantation, FL 33324 No data

Debts

Document Number Status Case Number Name of Court Date of Entry Expiration Date Amount Due Plaintiff
J16000679005 TERMINATED 1000000723631 ORANGE 2016-10-03 2036-10-21 $ 75,694.74 STATE OF FLORIDA, DEPARTMENT OF REVENUE, OUT OF STATE COLLECTIONS UNIT, 1415 W US HIGHWAY 90 STE 115, LAKE CITY FL320556156

Documents

Name Date
ANNUAL REPORT 2024-03-04
ANNUAL REPORT 2023-04-25
ANNUAL REPORT 2022-04-05
ANNUAL REPORT 2021-04-24
ANNUAL REPORT 2020-05-27
ANNUAL REPORT 2019-03-20
ANNUAL REPORT 2018-04-16
ANNUAL REPORT 2017-04-04
ANNUAL REPORT 2016-03-29
ANNUAL REPORT 2015-01-21

Related by officers

Mark Ladd W

WEST COAST ENDOSCOPY HOLDINGS, LLC SCA-SAND LAKE, LLC SCA-GROVE PLACE, LLC COLONIAL OUTPATIENT SURGERY CENTER, LLC SURGICAL HEALTH OF ORLANDO, LLC CORNERSTONE SURGERY CENTER, LLC SCA-DORAL, LLC JACKSONVILLE AMBULATORY SURGERY CENTER, LLC SPECIALISTS IN UROLOGY SURGERY CENTER, LLC SHC MELBOURNE, INC.

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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