| Entity Name: | WATERSIDE MEDICAL LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 17 Dec 2012 (12 years ago) |
| Date of dissolution: | 25 Sep 2015 (9 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2015 (9 years ago) |
| Document Number: | L12000157219 |
| FEI/EIN Number | 46-1600132 |
| Address: | 2950 9th St. North,, Naples, FL, 34103, US |
| Mail Address: | 2950 9th St. North,, Naples, FL, 34103, US |
| ZIP code: | 34103 |
| County: | Collier |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1518205038 | 2013-01-17 | 2013-08-22 | 5064 SEASHELL AVE, NAPLES, FL, 341032428, US | 311 9TH ST N, NAPLES, FL, 341025885, US | |||||||||||||||||||||||||
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| Phone | +1 239-293-4140 |
| Fax | 2392543105 |
Authorized person
| Name | MATTHEW L BLACK |
| Role | MANAGER |
| Phone | 2392934140 |
Taxonomy
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| License Number | M80046 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE 855-B |
| Number | HG441A |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Black Matthew L | Agent | 2950 9TH STREET NORTH STE 13, NAPLES, FL, 34103 |
| Name | Role | Address |
|---|---|---|
| BLACK MATTHEW L | Manager | 2950 9th St. North,, Naples, FL, 34103 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G13000067817 | WATERSIDE MEDICAL, LLC. | EXPIRED | 2013-07-05 | 2018-12-31 | No data | 5064 SEASHELL AVE., NAPLES, FL, 34103 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2015-09-25 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-01-06 | 2950 9th St. North,, Suite 13, Naples, FL 34103 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-06 | 2950 9th St. North,, Suite 13, Naples, FL 34103 | No data |
| LC STMNT OF RA/RO CHG | 2014-01-02 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-01-02 | 2950 9TH STREET NORTH STE 13, NAPLES, FL 34103 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-04-05 | Black, Matthew L | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2014-01-09 |
| CORLCRACHG | 2014-01-02 |
| ANNUAL REPORT | 2013-04-05 |
| Florida Limited Liability | 2012-12-17 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
