| Entity Name: | AHAVA-5772, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 14 Jul 2015 (10 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 19 Oct 2016 (8 years ago) |
| Document Number: | L15000120806 |
| FEI/EIN Number | 47-4582604 |
| Address: | 4200 N. Ocean Drive, 1-1103, Singer Island, FL 33404 |
| Mail Address: | 5540 PGA Blvd, Suite 100, PALM BEACH GARDENS, FL 33418 |
| ZIP code: | 33404 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1417403221 | 2016-08-31 | 2016-09-02 | 5540 PGA BOULEVARD, SUITE 100, PALM BEACH GARDENS, FL, 33418, US | 5540 PGA BOULEVARD, SUITE 100, PALM BEACH GARDENS, FL, 33418, US | |||||||||||||||||||||||
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| Phone | +1 561-596-2714 |
Authorized person
| Name | DR. BETH JOY KOZAK |
| Role | MANAGER |
| Phone | 5615962714 |
Taxonomy
| Taxonomy Code | 111N00000X - Chiropractor |
| License Number | CH7712 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | ES056Z |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AHAVA-5772, LLC PLAN | 2023 | 474582604 | 2024-06-26 | AHAVA-5772, LLC | 11 | |||||||||||||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-06-26 |
| Name of individual signing | STEVEN KOZAK |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2024-06-26 |
| Name of individual signing | STEVEN KOZAK |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2021-01-15 |
| Business code | 621310 |
| Sponsor’s telephone number | 5613025600 |
| Plan sponsor’s address | 5540 PGA BLVD, STE 100, PALM BEACH GARDENS, FL, 33418 |
Signature of
| Role | Plan administrator |
| Date | 2022-10-04 |
| Name of individual signing | STEVEN KOZAK |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2022-10-04 |
| Name of individual signing | STEVEN KOZAK |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| SIMONSON, PAUL E | Agent | 3100 JASMINE DRIVE, DELRAY BEACH, FL 33483 |
| Name | Role | Address |
|---|---|---|
| KOZAK, BETH J | Manager | 4200 N. Ocean Dr, 1-1103 Singer Island, FL 33404 |
| KOZAK, STEVEN | Manager | 4200 N. Ocean Dr, 1-1103 Singer Island, FL 33404 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G22000155177 | NAMASTE CHIROPRACTIC | ACTIVE | 2022-12-15 | 2027-12-31 | No data | 5540 PGA BLVD, SUIT 100, PALM BEACH GARDENS, FL, 33418 |
| G21000105082 | AHAVA-5772, LLC | ACTIVE | 2021-08-12 | 2026-12-31 | No data | 5540 PGA BLVD, SUITE 100, PALM BEACH GARDENS, FL, 33418 |
| G15000075998 | NAMASTE CHIROPRACTIC | EXPIRED | 2015-07-22 | 2020-12-31 | No data | 209 EAGLETON LAKES BLVD, PALM BEACH GARDENS, FL, 33418 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2018-04-26 | 4200 N. Ocean Drive, 1-1103, Singer Island, FL 33404 | No data |
| REINSTATEMENT | 2016-10-19 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2016-10-19 | 4200 N. Ocean Drive, 1-1103, Singer Island, FL 33404 | No data |
| REGISTERED AGENT NAME CHANGED | 2016-10-19 | SIMONSON, PAUL E | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-29 |
| ANNUAL REPORT | 2023-01-12 |
| ANNUAL REPORT | 2022-01-25 |
| ANNUAL REPORT | 2021-03-12 |
| ANNUAL REPORT | 2020-03-18 |
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-04-26 |
| ANNUAL REPORT | 2017-03-20 |
| REINSTATEMENT | 2016-10-19 |
| Florida Limited Liability | 2015-07-14 |
Date of last update: 20 Jan 2025
Sources: Florida Department of State
