| Entity Name: | HOLLYWOOD DIALYSIS, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Company |
| Status: | Active |
| Date Filed: | 14 Nov 2012 (12 years ago) |
| Document Number: | M12000006357 |
| FEI/EIN Number | 46-1383535 |
| Address: | 920 Winter Street, Waltham, MA 02451 |
| Mail Address: | 920 Winter Street, Waltham, MA 02451 |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558792960 | 2013-12-11 | 2023-10-23 | 4000 HOLLYWOOD BLVD STE 175S, HOLLYWOOD, FL, 330216775, US | 4000 HOLLYWOOD BLVD STE 175S, HOLLYWOOD, FL, 330216775, US | |||||||||||||||||||||
|
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| Phone | +1 954-962-3100 |
| Fax | 9549623200 |
Authorized person
| Name | BARRY L. BLANTON |
| Role | VICE PRESIDENT |
| Phone | 7816999000 |
Taxonomy
| Taxonomy Code | 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 012350600 |
| State | FL |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| Weiner, Neil J. | Manager | 920 Winter Street, Waltham, MA 02451 |
| Hashmi, Syed | Manager | 920 Winter Street, Waltham, MA 02451 |
| Rice, Richard | Manager | 920 Winter Street, Waltham, MA 02451 |
| Brentar , Ginnie | Manager | 920 Winter Street, Waltham, MA 02451 |
| Cius, Dinley | Manager | 920 Winter Street, Waltham, MA 02451 |
| Name | Role | Address |
|---|---|---|
| Mello, Bryan | Authorized Signor | 920 Winter Street, Waltham, MA 02451 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G22000122521 | FRESENIUS KIDNEY CARE HOLLYWOOD-BOULEVARD | ACTIVE | 2022-09-29 | 2027-12-31 | No data | 14000 HOLLYWOOD BLVD STE 175S, HOLLYWOOD, FL, 33021 |
| G21000163249 | FRESENIUS KIDNEY CARE HOLLYWOOD-BOULEVARD | ACTIVE | 2021-12-09 | 2026-12-31 | No data | 4000 HOLLYWOOD BLVD,STE 175S, HOLLYWOOD, FL, 33021 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-01-05 | 920 Winter Street, Waltham, MA 02451 | No data |
| CHANGE OF MAILING ADDRESS | 2024-01-05 | 920 Winter Street, Waltham, MA 02451 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-05 |
| ANNUAL REPORT | 2023-02-24 |
| ANNUAL REPORT | 2022-05-05 |
| ANNUAL REPORT | 2021-04-17 |
| ANNUAL REPORT | 2020-06-04 |
| ANNUAL REPORT | 2019-03-20 |
| ANNUAL REPORT | 2018-04-06 |
| ANNUAL REPORT | 2017-04-17 |
| ANNUAL REPORT | 2016-04-13 |
| ANNUAL REPORT | 2015-04-11 |
Date of last update: 23 Jan 2025
Sources: Florida Department of State
