| Entity Name: | DR. PHILLIPS MEDICAL WELLNESS CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 06 Oct 2017 (7 years ago) |
| Document Number: | L17000207114 |
| FEI/EIN Number | 82-3009090 |
| Address: | 2915 LAKEVIEW DRIVE, CASSELBERRY, FL, 32730, US |
| Mail Address: | 2915 LAKEVIEW DRIVE, CASSELBERRY, FL, 32730, US |
| ZIP code: | 32730 |
| County: | Seminole |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1225549603 | 2017-10-12 | 2021-03-25 | 3300 S FISKE BLVD, ROCKLEDGE, FL, 329554306, US | 2915 LAKEVIEW DR STE 1001, FERN PARK, FL, 327302009, US | |||||||||||||||||||||||
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| Phone | +1 407-960-1465 |
| Fax | 4073356945 |
| Phone | +1 407-900-0613 |
Authorized person
| Name | DR. MARYAM PHILLIPS |
| Role | OWNER |
| Phone | 4079000613 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | FL MEDICARE |
| Number | NH873 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DR.PHILLIPS MEDICAL WELLNESS CENTER 401(K) PLAN | 2022 | 823009090 | 2023-05-27 | DR.PHILLIPS MEDICAL WELLNESS CENTER | 6 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2023-05-27 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621112 |
| Sponsor’s telephone number | 4079000613 |
| Plan sponsor’s address | 2915 LAKEVIEW DR, 1001, CASSLEBERRY, FL, 32730 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1645 E 6TH STREET, SUITE 200, AUSTIN, TX, 78702 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2022-05-31 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2020-01-01 |
| Business code | 621112 |
| Sponsor’s telephone number | 4079000613 |
| Plan sponsor’s address | 2905 LAKEVIEW DR, CASSLEBERRY, FL, 32730 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 3050 S DELAWARE ST, #202, SAN MATEO, CA, 94403 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2021-05-27 |
| Name of individual signing | CAROL HO |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| PHILLIPS MARYAM | Agent | 2915 LAKEVIEW DRIVE, CASSELBERRY, FL, 32730 |
| Name | Role | Address |
|---|---|---|
| PHILLIPS MARYAM | Manager | 2915 LAKEVIEW DRIVE, CASSELBERRY, FL, 32730 |
| Name | Role | Address |
|---|---|---|
| SADRACK RIDA | Member | 2915 LAKEVIEW DRIVE, CASSELBERRY, FL, 32730 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-01-04 | 2915 LAKEVIEW DRIVE, 1001, CASSELBERRY, FL 32730 | No data |
| CHANGE OF MAILING ADDRESS | 2021-01-12 | 2915 LAKEVIEW DRIVE, 1001, CASSELBERRY, FL 32730 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-01-12 | 2915 LAKEVIEW DRIVE, 1001, CASSELBERRY, FL 32730 | No data |
| REGISTERED AGENT NAME CHANGED | 2020-05-07 | PHILLIPS, MARYAM | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-06 |
| ANNUAL REPORT | 2024-01-04 |
| ANNUAL REPORT | 2023-01-23 |
| ANNUAL REPORT | 2022-01-21 |
| ANNUAL REPORT | 2021-01-12 |
| ANNUAL REPORT | 2020-05-07 |
| ANNUAL REPORT | 2019-01-17 |
| ANNUAL REPORT | 2018-01-15 |
| Florida Limited Liability | 2017-10-06 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
