| Entity Name: | ST. JOHNS BIOMEDICAL LABORATORIES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 16 Oct 1989 (35 years ago) |
| Document Number: | L23505 |
| FEI/EIN Number | 59-2974661 |
| Address: | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 |
| Mail Address: | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 |
| ZIP code: | 32086 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1821001330 | 2006-08-14 | 2008-06-17 | PO BOX 860206, 165 SOUTHPARK BLVD, ST. AUGUSTINE, FL, 320860206, US | 165 SOUTHPARK BLVD, SUITE A, ST AUGUSTINE, FL, 320864101, US | |||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||
| Phone | +1 904-824-5497 |
| Fax | 9048248257 |
Authorized person
| Name | EDWIN OLIVA SIA |
| Role | DIRECTOR/OWNER |
| Phone | 9048245497 |
Taxonomy
| Taxonomy Code | 291U00000X - Clinical Medical Laboratory |
| License Number | 800001722 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | CLIA |
| Number | 10D0645082 |
| State | FL |
| Issuer | CLINICAL LAB LICENSE |
| Number | 800001722 |
| State | FL |
| Issuer | MEDICAID |
| Number | 030142600 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ST JOHNS BIOMEDICAL LABORATORIES PROFIT SHARING PLAN | 2012 | 592974661 | 2013-09-24 | ST JOHNS BIOMEDICAL LABORATORIES INC | 5 | |||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Administrator’s EIN | 592974661 |
| Plan administrator’s name | EDWIN O SIA |
| Plan administrator’s address | PO BOX 860206, JACKSONVILLE, FL, 32086 |
| Administrator’s telephone number | 9048245497 |
Number of participants as of the end of the plan year
| Active participants | 5 |
| Other retired or separated participants entitled to future benefits | 2 |
| Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 0 |
Signature of
| Role | Plan administrator |
| Date | 2013-09-24 |
| Name of individual signing | EDWIN SIA |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2013-09-24 |
| Name of individual signing | EDWIN SIA |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1992-01-01 |
| Business code | 621510 |
| Plan sponsor’s DBA name | ST JOHNS BIOMEDICAL LABORATORIES INC |
| Plan sponsor’s mailing address | PO BOX 860206, ST AUGUSTINE, FL, 32086 |
| Plan sponsor’s address | 165 SOUTHPARK BLVD, ST AUGUSTINE, FL, 32086 |
Plan administrator’s name and address
| Administrator’s EIN | 592974661 |
| Plan administrator’s name | ST JOHNS BIOMEDICAL LABORATORIES INC |
| Plan administrator’s address | PO BOX 860206, ST AUGUSTINE, FL, 32086 |
Number of participants as of the end of the plan year
| Active participants | 5 |
| Other retired or separated participants entitled to future benefits | 2 |
| Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 0 |
Signature of
| Role | Plan administrator |
| Date | 2012-10-31 |
| Name of individual signing | EDWIN SIA |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1992-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9048245497 |
| Plan sponsor’s DBA name | ST JOHNS BIOMEDICAL LABORATORIES INC |
| Plan sponsor’s mailing address | PO BOX 860206, ST AUGUSTINE, FL, 32086 |
| Plan sponsor’s address | 165 SOUTHPARK BLVD SUITE A, ST AUGUSTINE, FL, 32086 |
Plan administrator’s name and address
| Administrator’s EIN | 592974661 |
| Plan administrator’s name | ST JOHNS BIOMEDICAL LABORATORIES INC |
| Plan administrator’s address | PO BOX 860206, ST AUGUSTINE, FL, 32086 |
| Administrator’s telephone number | 9048245497 |
Number of participants as of the end of the plan year
| Active participants | 5 |
| Retired or separated participants receiving benefits | 0 |
| Other retired or separated participants entitled to future benefits | 1 |
| Deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 0 |
| Number of participants with account balances as of the end of the plan year | 0 |
| Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 0 |
Signature of
| Role | Plan administrator |
| Date | 2010-10-13 |
| Name of individual signing | EDWIN SIA |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Sia, Edwin O, Dr. | Agent | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 |
| Name | Role | Address |
|---|---|---|
| SIA, EDWIN O. | President | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2014-03-03 | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 | No data |
| REGISTERED AGENT NAME CHANGED | 2014-03-03 | Sia, Edwin O, Dr. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-03-03 | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2013-01-21 | 165 SOUTH PARK BLVD STE A, ST AUGUSTINE, FL 32086 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-29 |
| ANNUAL REPORT | 2024-03-05 |
| ANNUAL REPORT | 2023-04-22 |
| ANNUAL REPORT | 2022-03-03 |
| ANNUAL REPORT | 2021-01-27 |
| ANNUAL REPORT | 2020-03-17 |
| ANNUAL REPORT | 2019-04-08 |
| ANNUAL REPORT | 2018-02-01 |
| ANNUAL REPORT | 2017-01-09 |
| ANNUAL REPORT | 2016-01-22 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
