| Entity Name: | CAMPBELLTON-GRACEVILLE HOSPITAL CORPORATION |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Inactive |
| Date Filed: | 19 Mar 2010 (15 years ago) |
| Date of dissolution: | 28 Sep 2018 (6 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 28 Sep 2018 (6 years ago) |
| Document Number: | N10000002896 |
| FEI/EIN Number | 596139709 |
| Address: | 5429 COLLEGE DRIVE, GRACEVILLE, FL, 32440, US |
| Mail Address: | P.O. BOX 231, GRACEVILLE, FL, 32440, US |
| ZIP code: | 32440 |
| County: | Jackson |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1306143839 | 2011-02-18 | 2011-10-03 | 5429 COLLEGE DRIVE, SUITE B, GRACEVILLE, FL, 324401858, US | 5429 COLLEGE DRIVE, SUITE B, GRACEVILLE, FL, 324401858, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-263-0639 |
| Fax | 8502639726 |
Authorized person
| Name | MR. JIMMY B RIGSBY |
| Role | ADMINISTRATOR |
| Phone | 8502634431 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 003227500(RHC) |
| State | FL |
| Issuer | MEDICAID |
| Number | 003227501 |
| State | FL |
| Issuer | MEDICAID |
| Number | 003227500 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| JORDAN MICHELLE B | Agent | 15112 HWY 90, CHIPLEY, FL, 32428 |
| Name | Role | Address |
|---|---|---|
| HICKS HESTON | Chairman | 1106 1st AVE, GRACEVILLE, FL, 32440 |
| Name | Role | Address |
|---|---|---|
| PELHAM PAT | Boar | 5228 SMOKEY ROAD, GRACEVILLE, FL, 32440 |
| JERNIGAN CHRIS | Boar | 1141 10th AVE, GRACEVILLE, FL, 32440 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| REINSTATEMENT | 2017-10-23 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2015-09-08 | 5429 COLLEGE DRIVE, GRACEVILLE, FL 32440 | No data |
| REGISTERED AGENT NAME CHANGED | 2015-09-08 | JORDAN, MICHELLE BLANKENSHIP | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-09-08 | 15112 HWY 90, CHIPLEY, FL 32428 | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J19000582666 | ACTIVE | 1000000838856 | JACKSON | 2019-08-26 | 2029-08-28 | $ 70,763.42 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, MARIANNA SERVICE CENTER, 4230 LAFAYETTE ST STE D, MARIANNA FL324468231 |
| J16000682835 | TERMINATED | 1000000724602 | LEON | 2016-10-17 | 2026-10-21 | $ 7,560.29 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, MARIANNA SERVICE CENTER, 4230 LAFAYETTE ST STE D, MARIANNA FL324468231 |
| J16000323992 | LAPSED | 16000055CAAXMX | JACKSON COUNTY CIRCUIT COURT | 2015-09-22 | 2021-05-26 | $31,230.76 | CANON FINANCIAL SERVICES, INC., 158 GAITHER DRIVE, SUITE 200, MOUNT LAUREL, NJ 08054 |
| Name | Date |
|---|---|
| REINSTATEMENT | 2017-10-23 |
| ANNUAL REPORT | 2016-03-08 |
| ANNUAL REPORT | 2015-09-08 |
| ANNUAL REPORT | 2014-02-11 |
| ANNUAL REPORT | 2013-03-22 |
| ANNUAL REPORT | 2012-02-09 |
| ANNUAL REPORT | 2011-07-05 |
| Domestic Non-Profit | 2010-03-19 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
