| Entity Name: | CHAMPION MEDICAL SUPPLIES, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Inactive |
| Date Filed: | 20 Jun 2017 (8 years ago) |
| Date of dissolution: | 25 Sep 2020 (4 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2020 (4 years ago) |
| Document Number: | L17000134111 |
| FEI/EIN Number | 82-1943151 |
| Address: | 9600 W SAMPLE ROAD, SUITE 206, CORAL SPRINGS, FL 33065 |
| Mail Address: | 9600 W SAMPLE ROAD, SUITE 206, CORAL SPRINGS, FL 33065 |
| ZIP code: | 33065 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1699295980 | 2017-06-27 | 2022-07-21 | 9600 W SAMPLE RD STE 206, CORAL SPRINGS, FL, 330654030, US | 9600 W SAMPLE RD STE 206, CORAL SPRINGS, FL, 330654030, US | |||||||||||||||
|
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| Phone | +1 888-505-3686 |
| Phone | +1 561-633-7341 |
Authorized person
| Name | ELIZABETH CROCKETT |
| Role | OWNER |
| Phone | 8885053686 |
Taxonomy
| Taxonomy Code | 332B00000X - Durable Medical Equipment & Medical Supplies |
| Is Primary | Yes |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHAMPION MEDICAL SUPPLIES RETIREMENT SAVINGS PLAN | 2019 | 821943151 | 2020-07-28 | CHAMPION MEDICAL SUPPLIES, LLC | 3 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2020-07-28 |
| Name of individual signing | AMY JAYNES |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2018-01-01 |
| Business code | 339110 |
| Sponsor’s telephone number | 5616337341 |
| Plan sponsor’s address | 9600 WEST SAMPLE RD. SUITE 206, CORAL SPRINGS, FL, 33065 |
Signature of
| Role | Plan administrator |
| Date | 2019-10-14 |
| Name of individual signing | AMY JAYNES |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| CROCKETT, ELIZABETH | Agent | 8534 DUKE CT EAST, BOYNTON BEACH, FL 33436 |
| Name | Role | Address |
|---|---|---|
| CROCKETT, ELIZABETH | Manager | 8534 DUKE CT EAST, BOYNTON BEACH, FL 33436 |
| CROCKETT, SHANITA | Manager | 7526 SW 6TH ST, NORTH LAUDERDALE, FL 33068 |
| Name | Role | Address |
|---|---|---|
| CROCKETT, ELIZABETH | Authorized Member | 8534 DUKE CT EAST, BOYNTON BEACH, FL 33436 |
| CROCKETT, SHANITA | Authorized Member | 7526 SW 6TH ST, NORTH LAUDERDALE, FL 33068 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-04-30 | 8534 DUKE CT EAST, BOYNTON BEACH, FL 33436 | No data |
| LC AMENDMENT | 2017-09-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2017-09-27 | 9600 W SAMPLE ROAD, SUITE 206, CORAL SPRINGS, FL 33065 | No data |
| CHANGE OF MAILING ADDRESS | 2017-09-27 | 9600 W SAMPLE ROAD, SUITE 206, CORAL SPRINGS, FL 33065 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2019-04-30 |
| ANNUAL REPORT | 2018-04-30 |
| LC Amendment | 2017-09-27 |
| Florida Limited Liability | 2017-06-20 |
Date of last update: 18 Jan 2025
Sources: Florida Department of State
