| Entity Name: | SHADETREE DERMATOLOGY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 17 Apr 2024 (10 months ago) |
| Document Number: | L24000175757 |
| Address: | 105 S Banana River Blvd, 2nd Floor, Cocoa Beach, FL 32931 |
| Mail Address: | 105 S Banana River Blvd, 2nd Floor, Cocoa Beach, FL 32931 |
| ZIP code: | 32931 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366297376 | 2024-04-22 | 2024-08-04 | 105 S BANANA RIVER BLVD FL 2, COCOA BEACH, FL, 329315041, US | 105 S BANANA RIVER BLVD FL 2, COCOA BEACH, FL, 329315041, US | |||||||||||||
|
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| Phone | +1 321-200-0346 |
Authorized person
| Name | DR. VANESSA EMILY JOHNSON |
| Role | DERMATOLOGIST (PHYSICIAN) |
| Phone | 3212000346 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| WHITE, BRADLEY F, ESQ | Agent | 2101 WAVERLY PLACE, MELBOURNE, FL 32901 |
| Name | Role | Address |
|---|---|---|
| JOHNSON, VANESSA, M.D. | Manager | 2110 EASTWOOD DRIVE, MERRITT ISLAND, FL 32952 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-08-27 | 105 S Banana River Blvd, 2nd Floor, Cocoa Beach, FL 32931 | No data |
| CHANGE OF MAILING ADDRESS | 2024-08-27 | 105 S Banana River Blvd, 2nd Floor, Cocoa Beach, FL 32931 | No data |
| Name | Date |
|---|---|
| Florida Limited Liability | 2024-04-17 |
Date of last update: 07 Jan 2025
Sources: Florida Department of State
