| Entity Name: | SEAGROVE BEACH MEDICAL CLINIC, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 24 Jul 2000 (25 years ago) |
| Date of dissolution: | 28 Sep 2018 (6 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 28 Sep 2018 (6 years ago) |
| Document Number: | P00000071496 |
| FEI/EIN Number | 593656227 |
| Address: | 5399 EAST HIGHWAY 30A, SUITE 5, SEAGROVE BEACH, FL, 32459 |
| Mail Address: | 5399 EAST HIGHWAY 30A, SUITE 5, SEAGROVE BEACH, FL, 32459 |
| ZIP code: | 32459 |
| County: | Walton |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1710022827 | 2007-02-20 | 2013-12-18 | 5399 E COUNTY HIGHWAY 30A, SUITE 5, SANTA ROSA BEACH, FL, 324596717, US | 5399 E COUNTY HIGHWAY 30A, SUITE 5, SANTA ROSA BEACH, FL, 324596717, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 850-231-6200 |
| Fax | 8502313500 |
Authorized person
| Name | MR. GEORGE NORMAN ROLL |
| Role | OWNER |
| Phone | 8502316200 |
Taxonomy
| Taxonomy Code | 261QU0200X - Urgent Care Clinic/Center |
| License Number | PA3191 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 290446200 |
| State | FL |
| Issuer | BLUE CROSS BLUS SHIELD |
| Number | 97275 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| ROLL GEORGE N | Agent | 45 CLUB HOUSE DRIVE, FREEPORT, FL, 32439 |
| Name | Role | Address |
|---|---|---|
| ROLL GEORGE N | Manager | 45 CLUB HOUSE DRIVE, FREEPORT, FL, 32439 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2007-01-16 | 45 CLUB HOUSE DRIVE, FREEPORT, FL 32439 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2017-03-03 |
| ANNUAL REPORT | 2016-04-08 |
| ANNUAL REPORT | 2015-03-18 |
| ANNUAL REPORT | 2014-01-10 |
| ANNUAL REPORT | 2013-02-21 |
| ANNUAL REPORT | 2012-04-10 |
| ANNUAL REPORT | 2011-02-18 |
| ANNUAL REPORT | 2010-04-12 |
| ANNUAL REPORT | 2009-04-30 |
| ANNUAL REPORT | 2008-04-24 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
