| Entity Name: | COASTAL SHOULDER SURGERY & SPORTS MEDICINE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 30 Jan 2023 (2 years ago) |
| Document Number: | L23000054510 |
| FEI/EIN Number | 934219548 |
| Address: | 8240 118th Ave, Largo, FL, 33773, US |
| Mail Address: | 8240 118th Ave, Largo, FL, 33773, US |
| ZIP code: | 33773 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922876796 | 2023-12-12 | 2023-12-12 | 8240 118TH AVE STE 350, LARGO, FL, 337735015, US | 8240 118TH AVE STE 350, LARGO, FL, 337735015, US | |||||||||||||
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| Phone | +1 706-596-8844 |
Authorized person
| Name | ROBERT LEWIS |
| Role | OWNER |
| Phone | 7065968844 |
Taxonomy
| Taxonomy Code | 207X00000X - Orthopaedic Surgery Physician |
| Is Primary | Yes |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| COASTAL SHOULDER SURGERY & SPORTS MEDICINE 401(K) PLAN | 2023 | 934219548 | 2024-05-09 | COASTAL SHOULDER SURGERY & SPORTS MEDICINE, LLC | 4 | |||||||||||||||||||||||||||||||
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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 | 2024-05-09 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| LEWIS ROBERT G | Agent | 8240 118th Ave, Largo, FL, 33773 |
| Name | Role | Address |
|---|---|---|
| LEWIS ROBERT G | Authorized Member | 8240 118th Ave, Largo, FL, 33773 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2024-02-05 | 8240 118th Ave, Ste 350, Largo, FL 33773 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-02-05 | 8240 118th Ave, Ste 350, Largo, FL 33773 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-11-20 | 8240 118th Ave, Ste 350, Largo, FL 33773 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| Florida Limited Liability | 2023-01-30 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
