| Entity Name: | SANDY MARTIN DERMATOLOGY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 10 Feb 2014 (11 years ago) |
| Date of dissolution: | 10 Jan 2018 (7 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 10 Jan 2018 (7 years ago) |
| Document Number: | L14000022606 |
| FEI/EIN Number | 46-4774988 |
| Address: | 13641 METROPOLIS AVENUE #102, FORT MYERS, FL, 33912, US |
| Mail Address: | 13641 METROPOLIS AVE, STE 102, FORT MYERS, FL, 33912, US |
| ZIP code: | 33912 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1265856256 | 2014-02-11 | 2014-08-04 | 1090 CAMELOT CIR, NAPLES, FL, 341191308, US | 13641 METROPOLIS AVE, STE 102, FORT MYERS, FL, 339124433, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 561-706-5422 |
| Fax | 8889901670 |
| Phone | +1 239-208-4408 |
Authorized person
| Name | DR. SANDY MARTIN |
| Role | CHIEF EXECUTIVE MANAGER |
| Phone | 2392084408 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| License Number | ME30746 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | HS963A |
| State | FL |
| Issuer | MEDICARE PTAN FOR SANDY MARTIN MD |
| Number | 93792T |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SANDY MARTIN DERMATOLOGY, LLC 401(K) PROFIT SHARING PLAN | 2017 | 464774988 | 2018-02-20 | SANDY MARTIN DERMATOLOGY, LLC | 4 | |||||||||||||||||||||||
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| SANDY MARTIN DERMATOLOGY, LLC 401(K) PROFIT SHARING PLAN | 2016 | 464774988 | 2017-02-14 | SANDY MARTIN DERMATOLOGY, LLC | 3 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2017-02-14 |
| Name of individual signing | SANDY MARTIN |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| MARTIN SANDY | Agent | 13641 METROPOLIS AVE, FORT MYERS, FL, 33912 |
| Name | Role | Address |
|---|---|---|
| MARTIN SANDY | Manager | 13641 METROPOLIS AVENUE #102, FORT MYERS, FL, 33912 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000015977 | MARTIN DERMATOLOGY | EXPIRED | 2014-03-03 | 2019-12-31 | No data | 1090 CAMELOT CIRCLE, NAPLES, FL, 34119 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2018-01-10 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2015-01-07 | 13641 METROPOLIS AVENUE #102, FORT MYERS, FL 33912 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-01-07 | 13641 METROPOLIS AVE, STE 102, FORT MYERS, FL 33912 | No data |
| LC AMENDMENT | 2014-02-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-02-27 | 13641 METROPOLIS AVENUE #102, FORT MYERS, FL 33912 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2017-01-14 |
| ANNUAL REPORT | 2016-01-23 |
| ANNUAL REPORT | 2015-01-07 |
| LC Amendment | 2014-02-27 |
| Florida Limited Liability | 2014-02-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
