| Entity Name: | SUMMIT DERMATOLOGY AND SPA, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 04 Apr 2022 (3 years ago) |
| Document Number: | L22000138731 |
| FEI/EIN Number | 881652321 |
| Address: | 2111 BANQUOS TRAIL, PENSACOLA, FL, 32503, US |
| Mail Address: | 2111 BANQUOS TRAIL, PENSACOLA, FL, 32503, US |
| ZIP code: | 32503 |
| County: | Escambia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1578206785 | 2022-04-15 | 2022-12-23 | 3298 SUMMIT BLVD STE 12, PENSACOLA, FL, 325034350, US | 3298 SUMMIT BLVD STE 12, PENSACOLA, FL, 325034350, US | |||||||||||||||||||||||
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| Phone | +1 850-746-0650 |
| Fax | 8507460651 |
| Phone | +1 850-518-3881 |
Authorized person
| Name | ANGIE LAING |
| Role | MANAGER |
| Phone | 8505183881 |
Taxonomy
| Taxonomy Code | 261QM2500X - Medical Specialty Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 018326600 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JONES ROBERT LIII ESQ | Agent | 501 COMMENDENCIA STREET, PENSACOLA, FL, 32502 |
| Name | Role | Address |
|---|---|---|
| CHAVAN RAHUL N | Manager | 2111 BANQUOS TRAIL, PENSACOLA, FL, 32503 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-04-24 |
| Florida Limited Liability | 2022-04-04 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
