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  5. SOUTH LAKE GASTROENTEROLOGY, INC.

SOUTH LAKE GASTROENTEROLOGY, INC.

Company Details

Entity Name: SOUTH LAKE GASTROENTEROLOGY, INC.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Active
Date Filed: 22 Dec 2005 (19 years ago)
Last Event: AMENDED AND RESTATEDARTICLES/NAME CHANGE
Event Date Filed: 31 May 2013 (12 years ago)
Document Number: P05000165886
FEI/EIN Number 204102308
Address: 821 OAKLEY SEAVER DR, Clermont, FL, 34711, US
Mail Address: 17545 Deer Isle CIr, Winter Garden, FL, 34711, US
ZIP code: 34711
County: Lake
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1467647685 2007-09-11 2014-07-18 PO BOX 120930, CLERMONT, FL, 347120930, US 2040 OAKLEY SEAVER DR, CLERMONT, FL, 347111962, US

Contacts
Phone +1 352-242-1665
Fax 3522431649

Authorized person
Name MR. RAMESH RAMPERSAD
Role ADMINISTRATOR
Phone 3522421665

Taxonomy
Taxonomy Code 174400000X - Specialist
License Number ME74082
State FL
Is Primary Yes

Other Provider Identifiers
Issuer AETNA
Number 5858631
State FL
Issuer MEDICARE INDIVIDUAL
Number E0302Z
State FL
Issuer MEDICAID
Number 256031300
State FL
Issuer FL BCBS
Number 43437
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2023 204102308 2024-09-13 SOUTH LAKE GASTROENTEROLOGY 29
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522428433
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT FLORIDA, FL, 34711

Signature of
Role Plan administrator
Date 2024-09-13
Name of individual signing SHIRLEY HORNER
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY PENSION PLAN 2023 204102308 2024-10-15 SOUTH LAKE GASTROENTEROLOGY 26
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522421665
Plan sponsor’s address 821 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2024-10-15
Name of individual signing ADEL ABOUELSEOUD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2024-10-15
Name of individual signing ADEL ABOUELSEOUD
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2022 204102308 2023-10-16 SOUTH LAKE GASTROENTEROLOGY 39
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 821 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2023-10-16
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY PENSION PLAN 2022 204102308 2023-10-11 SOUTH LAKE GASTROENTEROLOGY 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 821 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 204102308
Plan administrator’s name SOUTH LAKE GASTROENTEROLOGY
Plan administrator’s address 821 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711
Administrator’s telephone number 3522521665

Signature of
Role Plan administrator
Date 2023-10-11
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY PENSION PLAN 2021 204102308 2022-12-13 SOUTH LAKE GASTROENTEROLOGY 21
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 204102308
Plan administrator’s name SOUTH LAKE GASTROENTEROLOGY
Plan administrator’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711
Administrator’s telephone number 3522521665

Signature of
Role Plan administrator
Date 2022-12-13
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2021 204102308 2022-12-13 SOUTH LAKE GASTROENTEROLOGY 34
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2022-12-13
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY PENSION PLAN 2020 204102308 2021-11-23 SOUTH LAKE GASTROENTEROLOGY 18
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Plan administrator’s name and address
Administrator’s EIN 204102308
Plan administrator’s name SOUTH LAKE GASTROENTEROLOGY
Plan administrator’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711
Administrator’s telephone number 3522521665

Signature of
Role Plan administrator
Date 2021-11-23
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2020 204102308 2021-11-23 SOUTH LAKE GASTROENTEROLOGY 28
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2021-11-23
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2019 204102308 2020-10-12 SOUTH LAKE GASTROENTEROLOGY 23
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2020-10-12
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature
SOUTH LAKE GASTROENTEROLOGY 401(K) PROFIT SHARING PLAN 2019 204102308 2021-11-23 SOUTH LAKE GASTROENTEROLOGY 25
File View Page
Three-digit plan number (PN) 002
Effective date of plan 2011-01-01
Business code 621111
Sponsor’s telephone number 3522521665
Plan sponsor’s address 2040 OAKLEY SEAVER DRIVE, CLERMONT, FL, 34711

Signature of
Role Plan administrator
Date 2021-11-23
Name of individual signing RAJAB ABUKHADRAH
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
ABUKHADRAH RAJAB Agent 17545 Deer Isle CIr, Winter Garden, FL, 34711

President

Name Role Address
ABU KHADRAH RAJAB KDR. President 821 OAKLEY SEAVER DR., CLERMONT, FL, 34711

Director

Name Role Address
ABUKHADRAH RAJAB Director 17545 Deer Isle Cir, Winter Garden, FL, 34787

Events

Event Type Filed Date Value Description
CHANGE OF MAILING ADDRESS 2021-12-27 821 OAKLEY SEAVER DR, Clermont, FL 34711 No data
CHANGE OF PRINCIPAL ADDRESS 2021-10-14 821 OAKLEY SEAVER DR, Clermont, FL 34711 No data
REGISTERED AGENT ADDRESS CHANGED 2016-03-28 17545 Deer Isle CIr, Winter Garden, FL 34711 No data
REGISTERED AGENT NAME CHANGED 2013-05-31 ABUKHADRAH, RAJAB No data
AMENDED AND RESTATEDARTICLES/NAME CHANGE 2013-05-31 SOUTH LAKE GASTROENTEROLOGY, INC. No data
REINSTATEMENT 2010-11-29 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2010-09-24 No data No data
CANCEL ADM DISS/REV 2009-10-09 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2009-09-25 No data No data
AMENDMENT AND NAME CHANGE 2006-02-07 SOUTH LAKE GASTROENTEROLOGY, P.A. No data

Documents

Name Date
ANNUAL REPORT 2024-03-10
ANNUAL REPORT 2023-02-10
ANNUAL REPORT 2022-03-04
ANNUAL REPORT 2021-04-05
ANNUAL REPORT 2020-06-25
ANNUAL REPORT 2019-04-02
ANNUAL REPORT 2018-03-09
ANNUAL REPORT 2017-03-17
ANNUAL REPORT 2016-03-28
ANNUAL REPORT 2015-03-20

Related by officers

ABUKHADRAH RAJAB

ISLAMIC SOCIETY OF CLERMONT, INC. SUNRISE ENDOS, LLC RA CRESCENT VENTURES LLC HOPELAND, LLC

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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