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  5. JERZY GRZEBIELUCH, MD, LLC

JERZY GRZEBIELUCH, MD, LLC

Company Details

Entity Name: JERZY GRZEBIELUCH, MD, LLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Co.
Status: Active
Date Filed: 10 Jul 2019 (6 years ago)
Last Event: LC AMENDMENT
Event Date Filed: 16 Sep 2019 (5 years ago)
Document Number: L19000177507
FEI/EIN Number 84-2608554
Address: 4 2ND STREET, SE, FORT WALTON BEACH, FL, 32548, US
Mail Address: 4 2ND STREET, SE, FORT WALTON BEACH, FL, 32548, US
ZIP code: 32548
County: Okaloosa
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1447809298 2019-09-04 2019-09-04 4 2ND ST SE, FORT WALTON BEACH, FL, 325485502, US 4 2ND ST SE, FORT WALTON BEACH, FL, 325485502, US

Contacts
Phone +1 850-864-2008
Fax 8508645008

Authorized person
Name JERZY GRZEBIELUCH
Role OWNER
Phone 8508642008

Taxonomy
Taxonomy Code 261Q00000X - Clinic/Center
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
JERZY GRZEBIELUCH, MD, LLC CASH BALANCE PLAN 2023 842608554 2024-07-09 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2024-07-09
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC 401(K) PLAN 2023 842608554 2024-04-29 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2024-04-29
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC 401(K) PLAN 2022 842608554 2023-06-28 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2023-06-28
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC CASH BALANCE PLAN 2022 842608554 2023-07-24 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2023-07-24
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC CASH BALANCE PLAN 2021 842608554 2022-03-16 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2022-03-16
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC 401(K) PLAN 2021 842608554 2022-02-19 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2022-02-19
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC 401(K) PLAN 2020 842608554 2021-01-18 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2021-01-18
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC CASH BALANCE PLAN 2020 842608554 2021-01-18 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2021-01-18
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC CASH BALANCE PLAN 2019 842608554 2020-09-21 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2020-09-21
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature
JERZY GRZEBIELUCH, MD, LLC 401(K) PLAN 2019 842608554 2020-05-25 JERZY GRZEBIELUCH, MD, LLC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 8508642008
Plan sponsor’s address 4 2ND STREET SE, FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2020-05-25
Name of individual signing JERZY GRZEBIELUCH
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
GRZEBIELUCH JERZY MD Agent 4 2ND STREET, SE, FORT WALTON BEACH, FL, 32548

Authorized Member

Name Role Address
GRZEBIELUCH JERZY MD Authorized Member 4 2ND STREET, SE, FORT WALTON BEACH, FL, 32548

Events

Event Type Filed Date Value Description
CHANGE OF PRINCIPAL ADDRESS 2025-02-01 4 2ND STREET, SE, FORT WALTON BEACH, FL 32548 No data
CHANGE OF MAILING ADDRESS 2025-02-01 4 2ND STREET, SE, FORT WALTON BEACH, FL 32548 No data
CHANGE OF PRINCIPAL ADDRESS 2024-02-01 4 2ND STREET, SE, FORT WALTON BEACH, FL 32548 No data
CHANGE OF MAILING ADDRESS 2024-02-01 4 2ND STREET, SE, FORT WALTON BEACH, FL 32548 No data
LC AMENDMENT 2019-09-16 No data No data

Documents

Name Date
ANNUAL REPORT 2024-01-20
ANNUAL REPORT 2023-01-30
ANNUAL REPORT 2022-01-12
ANNUAL REPORT 2021-02-01
ANNUAL REPORT 2020-01-16
LC Amendment 2019-09-16
Florida Limited Liability 2019-07-10

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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