| Entity Name: | INTRACOASTAL DERMATOLOGY, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 25 Sep 2012 (12 years ago) |
| Date of dissolution: | 21 Sep 2023 (a year ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 21 Sep 2023 (a year ago) |
| Document Number: | L12000122797 |
| FEI/EIN Number | 36-4743222 |
| Address: | 4776 HODGES BLVD #105, JACKSONVILLE, FL, 32224, US |
| Mail Address: | 4776 HODGES BLVD #105, JACKSONVILLE, FL, 32224, US |
| ZIP code: | 32224 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1194079988 | 2012-11-01 | 2022-01-24 | 4776 HODGES BLVD STE 105, JACKSONVILLE, FL, 322247218, US | 4776 HODGES BLVD STE 105, JACKSONVILLE, FL, 322247218, US | |||||||||||||||||
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| Phone | +1 904-655-5310 |
Authorized person
| Name | DR. KENDALL ADKISSON |
| Role | MANAGER |
| Phone | 9046555310 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| License Number | ME110325 |
| State | FL |
| Is Primary | Yes |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| INTRACOASTAL DERMATOLOGY RETIREMENT SAVINGS PLAN | 2023 | 364743222 | 2024-10-11 | INTRACOASTAL DERMATOLOGY | 22 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-10-11 |
| Name of individual signing | KEVIN CHEEZUM |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 9044048555 |
| Plan sponsor’s address | 4776 HODGES BOULEVARD, SUITE 105, JACKSONVILLE, FL, 32224 |
Signature of
| Role | Plan administrator |
| Date | 2023-07-29 |
| Name of individual signing | KEVIN CHEEZUM |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 9044048555 |
| Plan sponsor’s address | 4776 HODGES BOULEVARD, SUITE 105, JACKSONVILLE, FL, 32224 |
Signature of
| Role | Plan administrator |
| Date | 2022-10-13 |
| Name of individual signing | KEVIN CHEEZUM |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 9044048555 |
| Plan sponsor’s address | 4776 HODGES BOULEVARD, SUITE 105, JACKSONVILLE, FL, 32224 |
Signature of
| Role | Plan administrator |
| Date | 2021-09-28 |
| Name of individual signing | KENDALL ADKISSON |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Stinson John | Agent | 4776 Hodges Blvd, JACKSONVILLE, FL, 32224 |
| Name | Role | Address |
|---|---|---|
| ADKISSON KENDALL | Manager | 4776 HODGES BLVD #105, JACKSONVILLE, FL, 32224 |
| O'Connell Florence MDr. | Manager | 4776 HODGES BLVD #105, JACKSONVILLE, FL, 32224 |
| Name | Role | Address |
|---|---|---|
| Stinson John | Prac | 4776 HODGES BLVD #105, JACKSONVILLE, FL, 32224 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2023-09-21 | No data | No data |
| REINSTATEMENT | 2021-09-29 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2020-03-31 | Stinson, John | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-03-04 | 4776 Hodges Blvd, Suite 105, JACKSONVILLE, FL 32224 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2013-02-21 | 4776 HODGES BLVD #105, JACKSONVILLE, FL 32224 | No data |
| CHANGE OF MAILING ADDRESS | 2013-02-21 | 4776 HODGES BLVD #105, JACKSONVILLE, FL 32224 | No data |
| LC AMENDMENT | 2013-01-14 | No data | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2023-09-21 |
| ANNUAL REPORT | 2022-05-10 |
| REINSTATEMENT | 2021-09-29 |
| ANNUAL REPORT | 2020-03-31 |
| ANNUAL REPORT | 2019-05-01 |
| ANNUAL REPORT | 2018-01-26 |
| ANNUAL REPORT | 2017-01-20 |
| ANNUAL REPORT | 2016-01-29 |
| ANNUAL REPORT | 2015-01-07 |
| ANNUAL REPORT | 2014-03-04 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 3028327100 | 2020-04-11 | 0491 | PPP | 4776 Hodges Blvd STE 105, JACKSONVILLE, FL, 32224-2209 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 02 Feb 2025
Sources: Florida Department of State
