| Entity Name: | NORTHEAST FLORIDA HEALTH SERVICES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 25 Sep 2002 (22 years ago) |
| Document Number: | N02000004883 |
| FEI/EIN Number | 550799729 |
| Address: | 1205 S. WOODLAND BLVD, DeLand, FL, 32720, US |
| Mail Address: | 1205 S. WOODLAND BLVD, DeLand, FL, 32720, US |
| ZIP code: | 32720 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1609543594 | 2021-08-27 | 2021-08-27 | 1205 S WOODLAND BLVD STE 3, DELAND, FL, 327207464, US | 1200 DELTONA BLVD, DELTONA, FL, 327256306, US | |||||||||||||||||||||||||||
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| Phone | +1 386-202-6025 |
| Phone | +1 386-327-6060 |
| Fax | 3862231799 |
Authorized person
| Name | REBECCA COLLIER |
| Role | CREDENTIALING/CONTRACTS ADMIN. |
| Phone | 3862026025 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QF0400X - Federally Qualified Health Center (FQHC) |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 687955120 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FAMILY HEALTH SOURCE 403(B) PLAN | 2020 | 550799729 | 2022-05-03 | NORTHEAST FLORIDA HEALTH SERVICES, INC. | 84 | |||||||||||||||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2022-05-03 |
| Name of individual signing | ALANNA ALVAREZ |
| Valid signature | Filed with authorized/valid electronic signature |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2018-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3862026025 |
| Plan sponsor’s address | 1205 S WOODLAND BLVD, DELAND, FL, 327207466 |
Signature of
| Role | Plan administrator |
| Date | 2022-03-07 |
| Name of individual signing | ALANNA ALVAREZ |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2018-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3862026025 |
| Plan sponsor’s DBA name | FAMILY HEALTH SOURCE |
| Plan sponsor’s address | 1205 S WOODLAND BLVD, DELAND, FL, 32720 |
Signature of
| Role | Plan administrator |
| Date | 2020-10-08 |
| Name of individual signing | LORETTA ASBURY |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2020-10-08 |
| Name of individual signing | VICTORIA COLEMAN |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2018-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3862026025 |
| Plan sponsor’s DBA name | FAMILY HEALTH SOURCE |
| Plan sponsor’s address | 1205 S WOODLAND BLVD, DELAND, FL, 32720 |
Signature of
| Role | Plan administrator |
| Date | 2019-10-14 |
| Name of individual signing | LAURIE ASBURY |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Asbury Laurie | Agent | 1205 S. Woodland Blvd, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| Rivera-Spelorzi Carmen M | Director | 1205 S. WOODLAND BLVD, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| Asbury Laurie | Chief Executive Officer | 1205 S. Woodland Blvd., DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| Valdez Hipolito | Chief Financial Officer | 1205 S. WOODLAND BLVD, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| Ramirez Bruines | Chief Operating Officer | 1205 S. WOODLAND BLVD, DeLand, FL, 32720 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000025800 | FAMILY HEALTH SOURCE | EXPIRED | 2016-03-10 | 2021-12-31 | No data | P.O. BOX 527, PIERSON, FL, 32180 |
| G10000028767 | FAMILY HEALTH SOURCE | EXPIRED | 2010-03-30 | 2015-12-31 | No data | P.O. BOX 527, PIERSON, FL, 32180 |
| G08162900346 | DELAND MEDICAL CENTER | EXPIRED | 2008-06-10 | 2013-12-31 | No data | P.O. BOX 527, PIERSON, FL, 32180 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2025-01-28 | 1205 S. WOODLAND BLVD, Suite 3, DeLand, FL 32720 | No data |
| CHANGE OF MAILING ADDRESS | 2025-01-28 | 1205 S. WOODLAND BLVD, Suite 3, DeLand, FL 32720 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2025-01-28 | 1205 S. Woodland Blvd, Suite 3, DeLand, FL 32720 | No data |
| REGISTERED AGENT NAME CHANGED | 2015-03-12 | Asbury, Laurie | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-28 |
| ANNUAL REPORT | 2024-01-10 |
| ANNUAL REPORT | 2023-02-08 |
| ANNUAL REPORT | 2022-02-03 |
| AMENDED ANNUAL REPORT | 2021-09-15 |
| ANNUAL REPORT | 2021-01-05 |
| ANNUAL REPORT | 2020-01-06 |
| ANNUAL REPORT | 2019-02-13 |
| ANNUAL REPORT | 2018-03-21 |
| ANNUAL REPORT | 2017-03-14 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
