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SELECTSKINMD LLC

Company Details

Entity Name: SELECTSKINMD LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 11 Jan 2016 (9 years ago)
Last Event: REINSTATEMENT
Event Date Filed: 03 Oct 2017 (7 years ago)
Document Number: L16000004116
FEI/EIN Number 81-1039499
Address: 1600 36TH STREET,, Vero Beach, FL, 32960, US
Mail Address: 1600 36TH STREET,, Vero Beach, FL, 32960, US
ZIP code: 32960
County: Indian River
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1427414168 2016-01-11 2016-03-16 1325 36TH ST, SUITE A, VERO BEACH, FL, 329606599, US 1325 36TH ST, SUITE A, VERO BEACH, FL, 329606599, US

Contacts
Phone +1 772-567-1164

Authorized person
Name MONIKA SRIVASTAVA
Role OWNER
Phone 7725671164

Taxonomy
Taxonomy Code 207ND0101X - MOHS-Micrographic Surgery Physician
License Number ME101443
State FL
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SELECTSKIN MD, LLC 401(K) PLAN 2023 811039499 2024-08-20 SELECTSKINMD, LLC 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2024-08-20
Name of individual signing CAROL ROSOFSKY
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2022 811039499 2023-06-05 SELECTSKINMD, LLC 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2023-06-05
Name of individual signing CAROL ROSOFSKY
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2021 811039499 2022-09-23 SELECTSKINMD, LLC 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2022-09-23
Name of individual signing CAROL ROSOFSKY
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2020 811039499 2021-05-07 SELECTSKINMD, LLC 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2021-05-07
Name of individual signing KELLI KEYS
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2019 811039499 2020-04-14 SELECTSKINMD, LLC 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2020-04-14
Name of individual signing KELLI KEYS
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2018 811039499 2019-05-30 SELECTSKINMD, LLC 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2019-05-30
Name of individual signing KELLI KEYS
Valid signature Filed with authorized/valid electronic signature
SELECTSKIN MD, LLC 401(K) PLAN 2017 811039499 2018-09-24 SELECTSKINMD, LLC 8
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-02-01
Business code 621111
Sponsor’s telephone number 7725693511
Plan sponsor’s address 1600 36TH STREET, SUITE B, VERO BEACH, FL, 32960

Signature of
Role Plan administrator
Date 2018-09-24
Name of individual signing KELLI KEYS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Srivastava Monika Agent 1600 36th Street, Vero Beach, FL, 32960

Authorized Member

Name Role Address
SRIVASTAVA MONIKA Authorized Member 1600 36th Street, Vero Beach, FL, 32960

Events

Event Type Filed Date Value Description
REGISTERED AGENT ADDRESS CHANGED 2019-02-18 1600 36th Street, B, Vero Beach, FL 32960 No data
CHANGE OF PRINCIPAL ADDRESS 2018-01-18 1600 36TH STREET,, SUITE B, Vero Beach, FL 32960 No data
CHANGE OF MAILING ADDRESS 2018-01-18 1600 36TH STREET,, SUITE B, Vero Beach, FL 32960 No data
REINSTATEMENT 2017-10-03 No data No data
REGISTERED AGENT NAME CHANGED 2017-10-03 Srivastava, Monika No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2017-09-22 No data No data

Documents

Name Date
ANNUAL REPORT 2024-01-29
ANNUAL REPORT 2023-01-23
ANNUAL REPORT 2022-01-27
ANNUAL REPORT 2021-01-15
ANNUAL REPORT 2020-01-21
ANNUAL REPORT 2019-02-18
ANNUAL REPORT 2018-01-18
REINSTATEMENT 2017-10-03
Florida Limited Liability 2016-01-11

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Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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