| Entity Name: | SKIN DERMATOLOGY AND COSMETIC SERVICES, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 02 Nov 2011 (13 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 20 Oct 2016 (8 years ago) |
| Document Number: | P11000095389 |
| FEI/EIN Number | 453732466 |
| Address: | 865 SAXON BLVD, Orange City, FL, 32763, US |
| Mail Address: | 426 S Riverside Drive, New Symrna Beach, FL, 32168, US |
| ZIP code: | 32763 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003582123 | 2021-08-18 | 2021-08-18 | 865 SAXON BLVD, ORANGE CITY, FL, 327638204, US | 84 PINNACLES DR STE 400, PALM COAST, FL, 321642324, US | |||||||||||||||||||||
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| Phone | +1 386-256-1969 |
| Fax | 4075997506 |
Authorized person
| Name | SHAWNA FRAME |
| Role | BILLING MANAGER |
| Phone | 4235255993 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 009563608 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Spradley Ellen G | Agent | 111 A Executive Circle, Daytona Beach, FL, 32114 |
| Name | Role | Address |
|---|---|---|
| Wheeler Ross C | Manager | 865 Saxon Blvd, Orange City, FL, 32763 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G18000078341 | SKIN DERMATOLOGY AND COSMETIC SERVICES, P.A. | EXPIRED | 2018-07-19 | 2023-12-31 | No data | 865 SAXON BLVD, ORANGE CITY, FL, 32763 |
| G12000101165 | SKIN DERMATOLOGY AND MED SPA | EXPIRED | 2012-10-16 | 2017-12-31 | No data | 5519 AVENUE DU SOLEIL, LUTZ, FL, 33558 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2024-01-31 | 111 A Executive Circle, Daytona Beach, FL 32114 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-01-31 | Spradley, Ellen G | No data |
| CHANGE OF MAILING ADDRESS | 2023-02-22 | 865 SAXON BLVD, Orange City, FL 32763 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-05-14 | 865 SAXON BLVD, Orange City, FL 32763 | No data |
| REINSTATEMENT | 2016-10-20 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| AMENDMENT | 2015-06-04 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-02-22 |
| ANNUAL REPORT | 2022-02-26 |
| ANNUAL REPORT | 2021-04-29 |
| ANNUAL REPORT | 2020-01-20 |
| ANNUAL REPORT | 2019-05-16 |
| AMENDED ANNUAL REPORT | 2018-06-19 |
| ANNUAL REPORT | 2018-02-15 |
| ANNUAL REPORT | 2017-04-19 |
| REINSTATEMENT | 2016-10-20 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
