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  5. HENDERSON HAVEN, INC.

HENDERSON HAVEN, INC.

Company Details

Entity Name: HENDERSON HAVEN, INC.
Jurisdiction: FLORIDA
Filing Type: Florida Not For Profit Corporation
Status: Active
Date Filed: 13 Aug 2003 (21 years ago)
Document Number: N03000006945
FEI/EIN Number 57-1181811
Address: 772 Foxridge Center Dr, ORANGE PARK, FL 32065
Mail Address: 772 Foxridge Center Dr, ORANGE PARK, FL 32065
ZIP code: 32065
County: Clay
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1427013655 2006-04-19 2022-07-21 2554 MOODY AVE, ORANGE PARK, FL, 320735937, US 2554 MOODY AVE, ORANGE PARK, FL, 320735937, US

Contacts
Phone +1 904-264-2522
Fax 9042157338

Authorized person
Name LEE HENDERSON
Role PRES CEO
Phone 9042642522

Taxonomy
Taxonomy Code 251C00000X - Developmentally Disabled Services Day Training Agency
License Number F001
State FL
Is Primary Yes
Taxonomy Code 251V00000X - Voluntary or Charitable Agency
License Number CH17033
State FL
Is Primary No
Taxonomy Code 305S00000X - Point of Service
License Number F001
State FL
Is Primary No

Other Provider Identifiers
Issuer MEDICAID
Number 683650096
State FL
Issuer MEDICAID
Number 683650098
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
HENDERSON HAVEN INC 401(K) PROFIT SHARING PLAN & TRUST 2023 571181811 2024-07-25 HENDERSON HAVEN, INC. 36
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621498
Sponsor’s telephone number 9042642522
Plan sponsor’s address 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Signature of
Role Plan administrator
Date 2024-07-25
Name of individual signing EDWARD ROJAS
Valid signature Filed with authorized/valid electronic signature
HENDERSON HAVEN INC 401(K) PROFIT SHARING PLAN & TRUST 2022 571181811 2023-06-23 HENDERSON HAVEN, INC. 33
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621498
Sponsor’s telephone number 9042642522
Plan sponsor’s address 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Signature of
Role Plan administrator
Date 2023-06-23
Name of individual signing EDWARD ROJAS
Valid signature Filed with authorized/valid electronic signature
HENDERSON HAVEN INC 401(K) PROFIT SHARING PLAN & TRUST 2021 571181811 2022-07-01 HENDERSON HAVEN, INC. 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621498
Sponsor’s telephone number 9042642522
Plan sponsor’s address 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Signature of
Role Plan administrator
Date 2022-07-01
Name of individual signing EDWARD ROJAS
Valid signature Filed with authorized/valid electronic signature
HENDERSON HAVEN INC 401(K) PROFIT SHARING PLAN & TRUST 2020 571181811 2021-04-30 HENDERSON HAVEN, INC. 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621498
Sponsor’s telephone number 9042642522
Plan sponsor’s address 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Signature of
Role Plan administrator
Date 2021-04-30
Name of individual signing EDWARD ROJAS
Valid signature Filed with authorized/valid electronic signature
HENDERSON HAVEN INC 401(K) PROFIT SHARING PLAN & TRUST 2019 571181811 2020-06-17 HENDERSON HAVEN, INC. 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621498
Sponsor’s telephone number 9042642522
Plan sponsor’s address 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Signature of
Role Plan administrator
Date 2020-06-17
Name of individual signing EDWARD ROJAS
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
HENDERSON, LEE . Agent 2554 MOODY AVE, ORANGE PARK, FL 32073

Director

Name Role Address
HENDERSON, LEE Director 2554 MOODY AVE, ORANGE PARK, FL 32073
HENDERSON, SHERRI A Director 2554 MOODY AVE, ORANGE PARK, FL 32073
Merwin, Keith Director 5110 Siesta del Rio Dr, Jacksonville, FL 32258
Pender, Vanessa Director 309 Marisco Way, Jacksonville, FL 32220

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G12000086636 METAMORPHOSES ACTIVE 2012-09-04 2027-12-31 No data 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065
G11000080069 FREE 2 BE ME ACTIVE 2011-08-11 2025-12-31 No data 772 FOXRIDGE CENTER DR, ORANGE PARK, FL, 32065

Events

Event Type Filed Date Value Description
CHANGE OF PRINCIPAL ADDRESS 2016-01-28 772 Foxridge Center Dr, ORANGE PARK, FL 32065 No data
CHANGE OF MAILING ADDRESS 2015-01-28 772 Foxridge Center Dr, ORANGE PARK, FL 32065 No data
REGISTERED AGENT NAME CHANGED 2004-01-05 HENDERSON, LEE . No data

Documents

Name Date
ANNUAL REPORT 2024-01-19
ANNUAL REPORT 2023-01-19
ANNUAL REPORT 2022-01-24
ANNUAL REPORT 2021-01-25
ANNUAL REPORT 2020-02-04
ANNUAL REPORT 2019-02-01
ANNUAL REPORT 2018-01-16
ANNUAL REPORT 2017-01-09
ANNUAL REPORT 2016-01-28
ANNUAL REPORT 2015-01-28

Related by officers

HENDERSON, LEE

ML&RB LLC HENDERSON WINDOWS & DOORS , LLC HOOPER SERVICES, INC. DELTA ELECTRIC OF JACKSONVILLE, INC. LEE HENDERSON FUNERAL HOME, INC. BETTON HILLS NEIGHBORHOOD ASSOCIATION, INC. N. O. T. R. PUBLICATIONS, INC. FRED ADDONIZIO, INC.

Related by address

No related companies by address

Date of last update: 06 Jan 2025

Sources: Florida Department of State

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