| Entity Name: | PHOENIX CM INCORPORATED |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 07 Jun 2011 (14 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 02 Nov 2012 (12 years ago) |
| Document Number: | N11000005560 |
| FEI/EIN Number | 452522877 |
| Address: | 1318 ARDMORE ST, SAINT AUGUSTINE, FL, 32092 |
| Mail Address: | 1318 Ardmore Street, SAINT AUGUSTINE, FL, 32092, US |
| ZIP code: | 32092 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1740687664 | 2014-11-20 | 2014-11-20 | 52 TUSCAN WAY STE 202-142, STE. 202-142, SAINT AUGUSTINE, FL, 320921850, US | 1225 W BEAVER ST STE 101, JACKSONVILLE, FL, 322041415, US | |||||||||||||||||||
|
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| Phone | +1 904-377-6735 |
Authorized person
| Name | ELLA B RUSSELL |
| Role | EXECUTIVE DIRECTOR |
| Phone | 9043776735 |
Taxonomy
| Taxonomy Code | 251B00000X - Case Management Agency |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 006238200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| RUSSELL ELLA B | Agent | 1318 ARDMORE ST, SAINT AUGUSTINE, FL, 32092 |
| Name | Role | Address |
|---|---|---|
| Canopii Michele | Director | 1701 Greentree Drive, Salisbury, MD, 21804 |
| STAPLEFOOTE LIONEL | Director | 8670 JEREMY DAVID CT, JACKSONVILLE, FL, 32244 |
| Name | Role | Address |
|---|---|---|
| STAPLEFOOTE LIONEL | President | 8670 JEREMY DAVID CT, JACKSONVILLE, FL, 32244 |
| Name | Role | Address |
|---|---|---|
| Phillips Bertha | Othe | 524 Douglas Fir Lane, Columbia, SC, 29229 |
| Name | Role | Address |
|---|---|---|
| Canopii Michele | Vice President | 1701 Greentree Drive, Salisbury, MD, 21804 |
| Name | Role | Address |
|---|---|---|
| MCGHEE CASSANDRA | Treasurer | 1535 BLANDING BLVD APT. 904, MIDDLEBURG, FL, 32068 |
| Name | Role | Address |
|---|---|---|
| Huntley Alice | Secretary | 1495 shadow Creek Drive, Orange Park, FL, 32065 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2017-01-16 | 1318 ARDMORE ST, SAINT AUGUSTINE, FL 32092 | No data |
| AMENDMENT | 2012-11-02 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-08 |
| ANNUAL REPORT | 2023-01-25 |
| ANNUAL REPORT | 2022-03-07 |
| ANNUAL REPORT | 2021-03-23 |
| ANNUAL REPORT | 2020-03-12 |
| ANNUAL REPORT | 2019-01-26 |
| ANNUAL REPORT | 2018-01-17 |
| ANNUAL REPORT | 2017-01-16 |
| ANNUAL REPORT | 2016-01-22 |
| ANNUAL REPORT | 2015-01-09 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
