| Entity Name: | PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 27 Oct 2016 (8 years ago) |
| Document Number: | L16000198580 |
| FEI/EIN Number | 81-4290198 |
| Address: | 2801 17th street, ST CLOUD, FL, 34769, US |
| Mail Address: | 2801 17TH STREET, SAINT CLOUD, FL, 34769, US |
| ZIP code: | 34769 |
| County: | Osceola |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1336682764 | 2016-12-03 | 2020-10-01 | 2801 17TH ST UNIT 202, SAINT CLOUD, FL, 347694939, US | 2801 17TH ST UNIT 202, SAINT CLOUD, FL, 347694939, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 407-906-1328 |
| Fax | 8664258143 |
Authorized person
| Name | JASON JEONG HWAN SONG |
| Role | MEDICAL DIRECTOR |
| Phone | 2673129857 |
Taxonomy
| Taxonomy Code | 208100000X - Physical Medicine & Rehabilitation Physician |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2081P2900X - Pain Medicine (Physical Medicine & Rehabilitation) Physician |
| Is Primary | Yes |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 020119900 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PALM TREE INTERVENTIONAL PAIN MANAGEMENT 401(K) PLAN | 2023 | 814290198 | 2024-09-19 | PALM TREE INTERVENTIONAL PAIN MANAGEMENT | 14 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-09-19 |
| Name of individual signing | JIIN SONG |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-09-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 4079061328 |
| Plan sponsor’s address | 2801 17TH STREET, UNIT 202, ST. CLOUD, FL, 34769 |
Signature of
| Role | Plan administrator |
| Date | 2023-06-01 |
| Name of individual signing | JIIN SONG |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-09-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 4079061328 |
| Plan sponsor’s address | 2801 17TH STREET, UNIT 202, ST. CLOUD, FL, 34769 |
Signature of
| Role | Plan administrator |
| Date | 2022-10-13 |
| Name of individual signing | JIIN SONG |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-09-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 4079061328 |
| Plan sponsor’s address | 2801 17TH STREET, UNIT 202, ST. CLOUD, FL, 34769 |
Signature of
| Role | Plan administrator |
| Date | 2021-09-24 |
| Name of individual signing | JIIN SONG |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role |
|---|---|
| UNITED STATES CORPORATION AGENTS, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| SONG JASON | Authorized Member | 2801 17TH STREET, SAINT CLOUD, FL, 34769 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000011317 | ALOHA ANTI-AGING INSTITUTE | ACTIVE | 2024-01-19 | 2029-12-31 | No data | 2801 17TH ST., STE. 201, SAINT CLOUD, FL, 34769 |
| G24000011322 | ALOE ANTI-AGING INSTITUTE | ACTIVE | 2024-01-19 | 2029-12-31 | No data | 2801 17TH ST STE 201, SAINT CLOUD, FL, 34769 |
| G20000108293 | PALM TREE PHYSICAL THERAPY | ACTIVE | 2020-08-21 | 2025-12-31 | No data | 2029 HICKORY TREE RD, ST. CLOUD, FL, 34772 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2023-02-02 | 476 RIVERSIDE AVE., JACKSONVILLE, FL 32202 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-10-07 | 2801 17th street, unit 202, ST CLOUD, FL 34769 | No data |
| CHANGE OF MAILING ADDRESS | 2020-10-02 | 2801 17th street, unit 202, ST CLOUD, FL 34769 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-11 |
| ANNUAL REPORT | 2024-01-19 |
| ANNUAL REPORT | 2023-01-19 |
| ANNUAL REPORT | 2022-01-24 |
| ANNUAL REPORT | 2021-01-18 |
| ANNUAL REPORT | 2020-01-17 |
| ANNUAL REPORT | 2019-02-08 |
| ANNUAL REPORT | 2018-03-09 |
| ANNUAL REPORT | 2017-04-26 |
| Florida Limited Liability | 2016-10-27 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
