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  5. Lori G. Polacek, M.D., Inc.

Lori G. Polacek, M.D., Inc.

Company Details

Name: Lori G. Polacek, M.D., Inc.
Jurisdiction: Rhode Island
Entity type: Domestic Profit Corporation
Status: Activ
Date of Organization in Rhode Island: 01 Oct 1992 (32 years ago)
Identification Number: 000069804
ZIP code: 02920
County: Providence County
Principal Address: 2000 CHAPEL VIEW BOULEVARD SUITE 110, CRANSTON, RI, 02920, USA
Purpose: TO ENGAGE IN A MEDICAL PRACTICE SPECIALIZING IN THE FIELD OF PLASTIC SURGERY AS WELL AS MEDICAL SERVICES.
NAICS: 621999 - All Other Miscellaneous Ambulatory Health Care Services
Fictitious names: Polacek Center for Plastic Surgery (trading name, 2008-04-03 - )

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2023 050467606 2024-05-21 LORI G. POLACEK M.D., INC. 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 4
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 2
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 6
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2024-05-21
Name of individual signing LORI POLACEK
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2022 050467606 2023-05-18 LORI G. POLACEK M.D., INC. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 5
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 2
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 6
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 1

Signature of
Role Plan administrator
Date 2023-05-18
Name of individual signing LORI POLACEK
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2021 050467606 2022-09-23 LORI G. POLACEK M.D., INC. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 4
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 1
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 4
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2022-09-23
Name of individual signing ANDREA DESIMONE
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2020 050467606 2021-07-28 LORI G. POLACEK M.D., INC. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 4
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 1
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 4
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2021-07-28
Name of individual signing LORI POLACEK
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2019 050467606 2020-07-07 LORI G. POLACEK M.D., INC. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 3
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 2
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 4
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 1

Signature of
Role Plan administrator
Date 2020-07-07
Name of individual signing LORI POLACEK
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2018 050467606 2019-08-30 LORI G. POLACEK M.D., INC. 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 4
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 4
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2019-08-30
Name of individual signing LORI POLACEK
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2017 050467606 2018-08-29 LORI G. POLACEK M.D., INC. 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s mailing address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920
Plan sponsor’s address 2000 CHAPEL VIEW BLVD SUITE #110, CRANSTON, RI, 02920

Number of participants as of the end of the plan year
Active participants 6
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 1
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 5
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2018-08-29
Name of individual signing LORI G. POLACEK MD
Valid signature Filed with authorized/valid electronic signature
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2016 050467606 2017-03-20 LORI G. POLACEK M.D., INC. 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2015 050467606 2016-05-09 LORI G. POLACEK M.D., INC. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202
LORI G. POLACEK M.D., INC. PROFIT SHARING PLAN 2014 050467606 2015-08-27 LORI G. POLACEK M.D., INC. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2015-08-27
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2014/04/23/20140423075332P030308610211001.pdf
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2014-04-23
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/05/23/20130523141446P030223917283001.pdf
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2013-05-23
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/07/27/20120727125702P040015371442001.pdf
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2012-07-27
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/08/16/20110816075816P030113165377001.pdf
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2011-08-16
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2010/05/10/20100510122932P030011560500001.pdf
Three-digit plan number (PN) 001
Effective date of plan 1993-01-01
Business code 621111
Sponsor’s telephone number 4013310202
Plan sponsor’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919

Plan administrator’s name and address
Administrator’s EIN 050467606
Plan administrator’s name LORI G. POLACEK M.D., INC.
Plan administrator’s address 1524 ATWOOD AVENUE, JOHNSTON, RI, 02919
Administrator’s telephone number 4013310202

Signature of
Role Plan administrator
Date 2010-05-10
Name of individual signing LORI G. POLACEK, MD
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
REAVIS & HASKELL, LLC Agent 245 WATERMAN STREET SUITE 109, PROVIDENCE, RI, 02906, USA

PRESIDENT / TREASURER / SECRETARY / DIRECTOR

Name Role Address
LORI G. POLACEK, M.D. PRESIDENT / TREASURER / SECRETARY / DIRECTOR 2000 CHAPEL VIEW BLVD #110 CRANSTON, RI 02920 USA

Filings

Number Name File Date
202454106130 Annual Report 2024-05-09
202332780320 Annual Report 2023-04-12
202215864420 Annual Report 2022-04-27
202188349320 Annual Report 2021-01-30
202035047180 Annual Report 2020-02-24
201986727990 Annual Report 2019-02-15
201858360050 Annual Report 2018-02-15
201734132360 Annual Report 2017-02-15
201692059680 Annual Report 2016-02-08
201566218470 Statement of Change of Registered/Resident Agent Office 2015-07-27

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 07 Oct 2024

Sources: Rhode Island Department of State

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