| Entity Name: | FLORIDA PROTON THERAPY INSTITUTE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 21 Dec 2001 (23 years ago) |
| Document Number: | N02000000009 |
| FEI/EIN Number | 010554709 |
| Address: | 2015 JEFFERSON STREET, JACKSONVILLE, FL, 32206 |
| Mail Address: | 2015 JEFFERSON STREET, JACKSONVILLE, FL, 32206 |
| ZIP code: | 32206 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891748257 | 2006-05-18 | 2019-11-05 | 2015 JEFFERSON ST, JACKSONVILLE, FL, 322063531, US | 2015 JEFFERSON ST, JACKSONVILLE, FL, 322063531, US | |||||||||||||||||||||||||||
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| Phone | +1 904-588-1239 |
| Fax | 9045881300 |
| Phone | +1 904-588-1263 |
Authorized person
| Name | NANCY MEDENHALL |
| Role | DIRECTOR, ACTIVE, ATTENDING |
| Phone | 9045881263 |
Taxonomy
| Taxonomy Code | 2085R0001X - Radiation Oncology Physician |
| License Number | ME39054 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2771470 00 |
| State | FL |
| LEI number | Registered As | Jurisdiction Of Formation | General Category | Entity Status | Entity created at | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 254900JZDATMNVTU2937 | N02000000009 | US-FL | GENERAL | ACTIVE | 2001-12-21 | |||||||||||||||||||
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| Legal | c/o C T Corporation System, 1200 South Pine Island Road, Plantation, US-FL, US, 33324 |
| Headquarters | 2015 Jefferson St, Jacksonville, US-FL, US, 32206 |
Registration details
| Registration Date | 2017-10-30 |
| Last Update | 2023-10-09 |
| Status | ISSUED |
| Next Renewal | 2024-10-13 |
| LEI Issuer | 5493001KJTIIGC8Y1R12 |
| Corroboration Level | FULLY_CORROBORATED |
| Data Validated As | N02000000009 |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FLORIDA PROTON THERAPY INSTITUTE, INC. 401(K) PLAN | 2010 | 010554709 | 2011-09-01 | FLORIDA PROTON THERAPY INSTITUTE, INC. | 95 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 010554709 |
| Plan administrator’s name | FLORIDA PROTON THERAPY INSTITUTE, INC. |
| Plan administrator’s address | 2015 NORTH JEFFERSON STREET, JACKSONVILLE, FL, 32206 |
| Administrator’s telephone number | 9045581424 |
Signature of
| Role | Plan administrator |
| Date | 2011-09-01 |
| Name of individual signing | TOMMIE L. ALLEN |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role |
|---|---|
| C T CORPORATION SYSTEM | Agent |
| Name | Role | Address |
|---|---|---|
| OKUNIEFF, MD PAUL | Secretary | 2000 SW Archer Rd, GAINESVILLE, FL, 32608 |
| Name | Role | Address |
|---|---|---|
| HUNT JENNIFER LDr. | Chairman | 1515 SW Archer Rd, GAINESVILLE, FL, 32608 |
| Name | Role | Address |
|---|---|---|
| HEATH KRISTIN A | Chief Executive Officer | 2015 JEFFERSON STREET, JACKSONVILLE, FL, 32206 |
| Name | Role | Address |
|---|---|---|
| MENDENHALL, PM.D. NANCY | Trustee | 2015 JEFFERSON STREET, JACKSONVILLE, FL, 32206 |
| MORRISON ALAN | Trustee | 23 SOUTH 23RD ST, PHILADELPHIA, PA, 19103 |
| Walters Gae Phd | Trustee | 2007 Alaqua Lakes Blvd, Longwood, FL, 32779 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000106963 | UF HEALTH PROTON THERAPY INSTITUTE | ACTIVE | 2014-10-22 | 2029-12-31 | No data | 2015 JEFFERSON ST, JACKSONVILLE, FL, 32206 |
| G06257700001 | UNIVERSITY OF FLORIDA PROTON THERAPY INSTITUTE | ACTIVE | 2006-09-14 | 2026-12-31 | No data | 2015 JEFFERSON STREET, ATTN: TOMMIE ALLEN, JACKSONVILLE, FL, 32206 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2020-10-28 | C T CORPORATION SYSTEM | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-10-28 | 1200 SOUTH PINE ISLAND ROAD, PLANTATION, FL 33324 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2007-02-20 | 2015 JEFFERSON STREET, JACKSONVILLE, FL 32206 | No data |
| CHANGE OF MAILING ADDRESS | 2007-02-20 | 2015 JEFFERSON STREET, JACKSONVILLE, FL 32206 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-05-28 |
| ANNUAL REPORT | 2023-06-14 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-03-23 |
| Reg. Agent Change | 2020-10-28 |
| ANNUAL REPORT | 2020-03-11 |
| ANNUAL REPORT | 2019-04-18 |
| ANNUAL REPORT | 2018-03-22 |
| ANNUAL REPORT | 2017-02-06 |
| ANNUAL REPORT | 2016-02-22 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
