0001959981-22-000001.txt : 20221230 0001959981-22-000001.hdr.sgml : 20221230 20221229191838 ACCESSION NUMBER: 0001959981-22-000001 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20221230 DATE AS OF CHANGE: 20221229 EFFECTIVENESS DATE: 20221230 FILER: COMPANY DATA: COMPANY CONFORMED NAME: ASC San Rafael LLC CENTRAL INDEX KEY: 0001959981 IRS NUMBER: 371908887 STATE OF INCORPORATION: WA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D SEC ACT: 1933 Act SEC FILE NUMBER: 021-469196 FILM NUMBER: 221499911 BUSINESS ADDRESS: STREET 1: 415 118TH AVENUE SE CITY: BELLEVUE STATE: WA ZIP: 98005 BUSINESS PHONE: (866) 688-5829 MAIL ADDRESS: STREET 1: 415 118TH AVENUE SE CITY: BELLEVUE STATE: WA ZIP: 98005 D 1 primary_doc.xml X0708 D LIVE 0001959981 ASC San Rafael LLC 415 118TH AVENUE SE BELLEVUE WA WASHINGTON 98005 (866) 688-5829 WASHINGTON None None Limited Liability Company true 2018 Dwayne Clark 415 118th Avenue SE Bellevue WA WASHINGTON 98005 Executive Officer Promoter Jerry C. Meyer 415 118th Avenue SE Bellevue WA WASHINGTON 98005 Executive Officer Ashley Rea 415 118th Avenue SE Bellevue WA WASHINGTON 98005 Executive Officer Adam Clark 415 118th Avenue SE Bellevue WA WASHINGTON 98005 Executive Officer Other Health Care Decline to Disclose 06b false 2022-12-21 false true false 0 28311530 28311530 0 false 106 0 0 0 false ASC San Rafael LLC /s/ Ben Freeburg Ben Freeburg Authorized Signatory 2022-12-29