| Entity Name: | SURGERY CENTER OF SOUTHWEST FLORIDA, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 16 Jun 2000 (25 years ago) |
| Date of dissolution: | 25 Sep 2020 (4 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2020 (4 years ago) |
| Document Number: | P00000058660 |
| FEI/EIN Number | 651022543 |
| Address: | 12631 WHITEHALL DRIVE, FORT MYERS, FL, 33907 |
| Mail Address: | 507 DEL PRADO BLVD. S, CAPE CORAL, FL, 33990 |
| ZIP code: | 33907 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1689624793 | 2006-05-11 | 2012-02-01 | 12631 WHITEHALL DR, FT MYERS, FL, 339073626, US | 12631 WHITEHALL DR, FT MYERS, FL, 339073626, US | |||||||||||||||||||||||||
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| Phone | +1 239-939-4758 |
| Fax | 2394797874 |
Authorized person
| Name | DR. PAUL R BRETTON |
| Role | MEDICAL DIRECTOR |
| Phone | 2399394758 |
Taxonomy
| Taxonomy Code | 261QA1903X - Ambulatory Surgical Clinic/Center |
| License Number | 1125 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 075319000 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SPIN-OFF TERMINATION PLAN FOR SURGERY CENTER OF SOUTHWEST FLORIDA, INC. | 2020 | 651022543 | 2021-07-25 | SURGERY CENTER OF SOUTHWEST FLORIDA, INC. | 5 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2021-07-25 |
| Name of individual signing | SHERYL SOUTHWICK |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-06-05 |
| Business code | 541214 |
| Sponsor’s telephone number | 2393377874 |
| Plan sponsor’s address | 12631 WHITEHALL DRIVE, FT. MYERS, FL, 33907 |
Signature of
| Role | Plan administrator |
| Date | 2021-08-25 |
| Name of individual signing | SHERYL SOUTHWICK |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| EVANS WILLIAM P | Agent | 12631 WHITEHALL DRIVE, FORT MYERS, FL, 33907 |
| Name | Role | Address |
|---|---|---|
| EVANS WILLIAM P | President | 5598 SUNDOWN HARBOUR COURT, FORT MYERS, FL, 33919 |
| Name | Role | Address |
|---|---|---|
| BORDEN JAMES D | Vice President | 3880 W RIVERSIDE DRIVE, FORT MYERS, FL, 33901 |
| Name | Role | Address |
|---|---|---|
| BRETTON PAUL R | Director | 4849 LAUREL LANE, FORT MYERS, FL, 33908 |
| Name | Role | Address |
|---|---|---|
| RIZZO JASPER J | Officer | 14169 REFLECTION LAKES DR, FORT MYERS, FL, 33907 |
| STRICKLAND MICHAEL G | Officer | 6680 DANIEL CT, FORT MYERS, FL, 33908 |
| Evans Blake P | Officer | 1221 CANTERBURY DR, FORT MYERS, FL, 33901 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2013-01-16 | EVANS, WILLIAM P | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-12-26 | 12631 WHITEHALL DRIVE, FORT MYERS, FL 33907 | No data |
| CHANGE OF MAILING ADDRESS | 2006-01-19 | 12631 WHITEHALL DRIVE, FORT MYERS, FL 33907 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2005-04-20 | 12631 WHITEHALL DRIVE, FORT MYERS, FL 33907 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-01-15 |
| ANNUAL REPORT | 2017-04-07 |
| ANNUAL REPORT | 2016-03-30 |
| ANNUAL REPORT | 2015-02-18 |
| ANNUAL REPORT | 2014-04-09 |
| ANNUAL REPORT | 2013-01-16 |
| Reg. Agent Change | 2012-12-26 |
| ANNUAL REPORT | 2012-02-09 |
| ANNUAL REPORT | 2011-01-27 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
