| Entity Name: | TRIDENT MEDICAL GROUP, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 29 Sep 2021 (3 years ago) |
| Date of dissolution: | 16 Feb 2024 (a year ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 16 Feb 2024 (a year ago) |
| Document Number: | P21000085122 |
| FEI/EIN Number | 87-2888744 |
| Address: | 382 NE 191ST STREET, MIAMI, FL 33179 |
| Mail Address: | 382 NE 191ST STREET, PMB 75481, MIAMI, FL 33179-3899 |
| ZIP code: | 33179 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1295407922 | 2021-09-30 | 2022-11-14 | 1256 FOLSOM ST, SAN FRANCISCO, CA, 941033817, US | 382 NE 191ST ST, PMB 75481, MIAMI, FL, 331793899, US | |||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 310-626-0149 |
| Fax | 8558362741 |
| Phone | +1 855-770-7771 |
Authorized person
| Name | DEVION SMITH |
| Role | DIRECTOR, PAYER CONTRACTING |
| Phone | 4243268711 |
Taxonomy
| Taxonomy Code | 171M00000X - Case Manager/Care Coordinator |
| Is Primary | No |
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207XX0004X - Orthopaedic Foot and Ankle Surgery Physician |
| Is Primary | No |
| Taxonomy Code | 2086S0129X - Vascular Surgery Physician |
| Is Primary | No |
| Taxonomy Code | 213E00000X - Podiatrist |
| Is Primary | No |
| Taxonomy Code | 213EP0504X - Public Medicine Podiatrist |
| Is Primary | Yes |
| Taxonomy Code | 213ES0103X - Foot & Ankle Surgery Podiatrist |
| Is Primary | No |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| HENDERSON, KIMBERLY, MD | Chief Executive Officer | 333 SE 2ND ST, SUITE 2000 MIAMI, FL 33131 |
| Name | Role | Address |
|---|---|---|
| HENDERSON, KIMBERLY, MD | Chief Financial Officer | 333 SE 2ND ST, SUITE 2000 MIAMI, FL 33131 |
| Name | Role | Address |
|---|---|---|
| HENDERSON, KIMBERLY, MD | Secretary | 333 SE 2ND ST, SUITE 2000 MIAMI, FL 33131 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2024-02-16 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2022-09-16 | 382 NE 191ST STREET, MIAMI, FL 33179 | No data |
| AMENDMENT | 2022-04-13 | No data | No data |
| AMENDMENT | 2022-03-16 | No data | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2024-02-16 |
| ANNUAL REPORT | 2023-09-15 |
| ANNUAL REPORT | 2022-09-16 |
| Amendment | 2022-04-13 |
| Amendment | 2022-03-16 |
| Domestic Profit | 2021-09-29 |
Date of last update: 13 Jan 2025
Sources: Florida Department of State
