| Entity Name: | FLORIDA INSTITUTE OF DERMATOLOGY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 31 Jan 2019 (6 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 17 Nov 2024 (3 months ago) |
| Document Number: | L19000032123 |
| FEI/EIN Number | 83-3575553 |
| Address: | 1991 DANIELS ROAD, WINTER GARDEN, FL 34787 |
| Mail Address: | 1991 DANIELS ROAD, WINTER GARDEN, FL 34787 |
| ZIP code: | 34787 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1912573684 | 2021-06-02 | 2021-06-02 | 201 N PARK AVE STE 204, APOPKA, FL, 327034147, US | 201 N PARK AVE STE 204, APOPKA, FL, 327034147, US | |||||||||||||||||||||
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| Phone | +1 407-395-3770 |
| Fax | 4073953779 |
Authorized person
| Name | MICHAEL WAUDO WANGIA |
| Role | PHYSICIAN/OWNER |
| Phone | 4073953770 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 103439400 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FLORIDA INSTITUTE OF DERMATOLOGY 401(K) PLAN | 2023 | 833575553 | 2024-05-13 | FLORIDA INSTITUTE OF DERMATOLOGY, LLC | 29 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-13 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| WANGIA, MICHAEL | Agent | 1991 Daniels Rd, Winter Garden, FL 34787 |
| Name | Role | Address |
|---|---|---|
| WANGIA, MICHAEL | Manager | 1991 Daniels Rd, Winter Garden, FL 34787 |
| Name | Role | Address |
|---|---|---|
| Taylor, Tonya | Authorized Member | 1991 DANIELS ROAD, WINTER GARDEN, FL 34787 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-11-17 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| REINSTATEMENT | 2022-10-03 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-03-15 | 1991 Daniels Rd, Winter Garden, FL 34787 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-11-23 | 1991 DANIELS ROAD, WINTER GARDEN, FL 34787 | No data |
| CHANGE OF MAILING ADDRESS | 2020-11-23 | 1991 DANIELS ROAD, WINTER GARDEN, FL 34787 | No data |
| REINSTATEMENT | 2020-11-20 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2020-11-20 | WANGIA, MICHAEL | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-11-17 |
| ANNUAL REPORT | 2023-07-10 |
| REINSTATEMENT | 2022-10-03 |
| ANNUAL REPORT | 2021-03-15 |
| REINSTATEMENT | 2020-11-20 |
| Florida Limited Liability | 2019-01-31 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 4607047109 | 2020-04-13 | 0491 | PPP | 1991 Daniels Rd, WINTER GARDEN, FL, 34787-4599 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 16 Feb 2025
Sources: Florida Department of State
