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  5. LAWRENCE R. BLACK, D.O., P.A.

LAWRENCE R. BLACK, D.O., P.A.

Company Details

Entity Name: LAWRENCE R. BLACK, D.O., P.A.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Inactive
Date Filed: 21 Dec 1995 (29 years ago)
Date of dissolution: 26 Sep 2014 (10 years ago)
Last Event: ADMIN DISSOLUTION FOR ANNUAL REPORT
Event Date Filed: 26 Sep 2014 (10 years ago)
Document Number: P95000096577
FEI/EIN Number 593350266
Address: 13691 METRO PARKWAY, SUITE 350, FORT MYERS, FL, 33912
Mail Address: 13691 METRO PARKWAY, SUITE 350, FORT MYERS, FL, 33912
ZIP code: 33912
County: Lee
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1619178654 2007-05-29 2013-04-03 13691 METRO PKWY, SUITE 350, FORT MYERS, FL, 339124327, US 13691 METRO PKWY, SUITE 350, FORT MYERS, FL, 339124327, US

Contacts
Phone +1 239-768-5313
Fax 2397689559

Authorized person
Name KAREN DESANTIS
Role OFFICE MANAGER
Phone 2397685313

Taxonomy
Taxonomy Code 174400000X - Specialist
License Number OS5736
State FL
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
LAWRENCE R. BLACK, D.O., P.A. 401(K) PROFIT SHARING PLAN & TRUST 2013 593350266 2014-01-27 LAWRENCE R. BLACK, D.O., P.A. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621111
Sponsor’s telephone number 2397685313
Plan sponsor’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912

Signature of
Role Plan administrator
Date 2014-01-27
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-01-27
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
LAWRENCE R. BLACK, D.O., P.A. 401(K) PROFIT SHARING PLAN & TRUST 2012 593350266 2013-06-07 LAWRENCE R. BLACK, D.O., P.A. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621111
Sponsor’s telephone number 2397685313
Plan sponsor’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912

Signature of
Role Plan administrator
Date 2013-06-07
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2013-06-07
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
LAWRENCE R. BLACK, D.O., P.A. 401(K) PROFIT SHARING PLAN & TRUST 2011 593350266 2012-07-30 LAWRENCE R. BLACK, D.O., P.A. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621111
Sponsor’s telephone number 2397685313
Plan sponsor’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912

Plan administrator’s name and address
Administrator’s EIN 593350266
Plan administrator’s name LAWRENCE R. BLACK, D.O., P.A.
Plan administrator’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912
Administrator’s telephone number 2397685313

Signature of
Role Plan administrator
Date 2012-07-30
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2012-07-30
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
LAWRENCE R. BLACK, D.O., P.A. MONEY PURCHASE PENSION PLAN 2010 593350266 2011-05-20 LAWRENCE R. BLACK, D.O., P.A. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621111
Sponsor’s telephone number 2397685313
Plan sponsor’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912

Plan administrator’s name and address
Administrator’s EIN 593350266
Plan administrator’s name LAWRENCE R. BLACK, D.O., P.A.
Plan administrator’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912
Administrator’s telephone number 2397685313

Signature of
Role Plan administrator
Date 2011-05-20
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-05-20
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
LAWRENCE R. BLACK, D.O., P.A. MONEY PURCHASE PENSION PLAN 2009 593350266 2010-10-04 LAWRENCE R. BLACK, D.O., P.A. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621111
Sponsor’s telephone number 2397685313
Plan sponsor’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912

Plan administrator’s name and address
Administrator’s EIN 593350266
Plan administrator’s name LAWRENCE R. BLACK, D.O., P.A.
Plan administrator’s address 13691 METRO PARKWAY SOUTH,, SUITE 350, FORT MYERS, FL, 33912
Administrator’s telephone number 2397685313

Signature of
Role Plan administrator
Date 2010-10-04
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-10-04
Name of individual signing LAWRENCE R. BLACK, D.O.
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
BLACK LAWRENCE R Agent 13691 METRO PKWY S, FT MYERS, FL, 33912

Director

Name Role Address
BLACK LAWRENCE R Director 13691 METRO PKWY S SUITE 350, FT MYERS, FL, 33912

President

Name Role Address
BLACK LAWRENCE R President 13691 METRO PKWY S SUITE 350, FT MYERS, FL, 33912

Secretary

Name Role Address
BLACK LAWRENCE R Secretary 13691 METRO PKWY S SUITE 350, FT MYERS, FL, 33912

Treasurer

Name Role Address
BLACK LAWRENCE R Treasurer 13691 METRO PKWY S SUITE 350, FT MYERS, FL, 33912

Events

Event Type Filed Date Value Description
ADMIN DISSOLUTION FOR ANNUAL REPORT 2014-09-26 No data No data
CHANGE OF MAILING ADDRESS 2011-01-28 13691 METRO PARKWAY, SUITE 350, FORT MYERS, FL 33912 No data
REINSTATEMENT 2011-01-28 No data No data
CHANGE OF PRINCIPAL ADDRESS 2011-01-28 13691 METRO PARKWAY, SUITE 350, FORT MYERS, FL 33912 No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2008-09-26 No data No data
CANCEL ADM DISS/REV 2006-04-24 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2005-09-16 No data No data

Documents

Name Date
ANNUAL REPORT 2013-02-07
ANNUAL REPORT 2012-03-21
REINSTATEMENT 2011-01-28
ANNUAL REPORT 2007-07-10
REINSTATEMENT 2006-04-24
ANNUAL REPORT 2004-03-29
ANNUAL REPORT 2003-01-29
ANNUAL REPORT 2002-01-21
ANNUAL REPORT 2001-01-29
ANNUAL REPORT 2000-02-04

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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