| Entity Name: | CLAY PRIMARY & FAMILY CARE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 27 Feb 2013 (12 years ago) |
| Last Event: | CONVERSION |
| Event Date Filed: | 27 Feb 2013 (12 years ago) |
| Document Number: | L13000030986 |
| FEI/EIN Number | 59-3060016 |
| Address: | 865 BLANDING BLVD., C/O MASSOUD MOSHIREE, M.D., ORANGE PARK, FL 32065 |
| Mail Address: | 865 BLANDING BLVD., C/O MASSOUD MOSHIREE, M.D., ORANGE PARK, FL 32065 |
| ZIP code: | 32065 |
| County: | Clay |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1730186792 | 2005-07-06 | 2022-07-21 | 865 BLANDING BLVD, ORANGE PARK, FL, 320658917, US | 865 BLANDING BLVD, ORANGE PARK, FL, 320658917, US | |||||||||||||||||||||||
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| Phone | +1 904-276-1133 |
| Fax | 9042761821 |
Authorized person
| Name | DR. MASSOUD MOSHIREE |
| Role | PRESIDENT/OWNER |
| Phone | 9042761133 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 255561100 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CLAY PRIMARY FAMILY CARE 401 K PROFIT SHARING PLAN TRUST | 2011 | 593060016 | 2012-06-19 | CLAY PRIMARY FAMILY CARE | 14 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 593060016 |
| Plan administrator’s name | CLAY PRIMARY FAMILY CARE |
| Plan administrator’s address | CENTER PA, 865 BLANDING BLVD, ORANGE PARK, FL, 320658917 |
| Administrator’s telephone number | 9042761133 |
Signature of
| Role | Plan administrator |
| Date | 2012-06-19 |
| Name of individual signing | CLAY PRIMARY FAMILY CARE |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2002-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9042761133 |
| Plan sponsor’s address | CENTER PA, 865 BLANDING BLVD, ORANGE PARK, FL, 32065 |
Plan administrator’s name and address
| Administrator’s EIN | 593060016 |
| Plan administrator’s name | CLAY PRIMARY FAMILY CARE |
| Plan administrator’s address | CENTER PA, 865 BLANDING BLVD, ORANGE PARK, FL, 32065 |
| Administrator’s telephone number | 9042761133 |
Signature of
| Role | Plan administrator |
| Date | 2011-04-26 |
| Name of individual signing | CLAY PRIMARY FAMILY CARE |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2002-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9042761133 |
| Plan sponsor’s address | CENTER PA, 865 BLANDING BLVD, ORANGE PARK, FL, 32065 |
Plan administrator’s name and address
| Administrator’s EIN | 593060016 |
| Plan administrator’s name | CLAY PRIMARY FAMILY CARE |
| Plan administrator’s address | CENTER PA, 865 BLANDING BLVD, ORANGE PARK, FL, 32065 |
| Administrator’s telephone number | 9042761133 |
Signature of
| Role | Plan administrator |
| Date | 2010-07-27 |
| Name of individual signing | CLAY PRIMARY FAMILY CARE |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Cyrus, Moshiree | Agent | 865 BLANDING BLVD., ORANGE PARK, FL 32065 |
| Name | Role | Address |
|---|---|---|
| MOSHIREE, MASSOUD M.D. | President | 865 BLANDING BLVD., ORANGE PARK, FL 32065 |
| Name | Role | Address |
|---|---|---|
| Moshiree, Cyrus | Chief Operating Officer | 865 BLANDING BLVD., ORANGE PARK, FL 32065 |
| Name | Role | Address |
|---|---|---|
| Moshiree, Mehri | Vice President | 865 BLANDING BLVD., ORANGE PARK, FL 32065 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2023-01-19 | Cyrus, Moshiree | No data |
| CONVERSION | 2013-02-27 | No data | CORPORATION WAS A CONVERSION RESULT. CONVERTING CORPORATION WAS S45430. CONVERSION NUMBER 700000129657 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-06-17 |
| ANNUAL REPORT | 2023-01-19 |
| ANNUAL REPORT | 2022-03-08 |
| ANNUAL REPORT | 2021-07-08 |
| ANNUAL REPORT | 2020-01-14 |
| ANNUAL REPORT | 2019-02-06 |
| ANNUAL REPORT | 2018-06-29 |
| ANNUAL REPORT | 2017-02-09 |
| ANNUAL REPORT | 2016-05-13 |
| ANNUAL REPORT | 2015-05-22 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 2998297209 | 2020-04-16 | 0491 | PPP | 865 BLANDING BLVD, ORANGE PARK, FL, 32065 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 7222738310 | 2021-01-28 | 0491 | PPS | 865 Blanding Blvd, Orange Park, FL, 32065-8917 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 22 Feb 2025
Sources: Florida Department of State
