| Entity Name: | AGAPE HEALTH & WELLNESS CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 04 Feb 2021 (4 years ago) |
| Document Number: | N21000000953 |
| FEI/EIN Number | 86-2575228 |
| Mail Address: | 11555 Central Parkway, 601, JACKSONVILLE, FL, 32224, US |
| Address: | 6138 Kennerly Road, Suite 150, JACKSONVILLE, FL, 32216, US |
| ZIP code: | 32216 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386223469 | 2021-04-06 | 2024-04-19 | 11555 CENTRAL PKWY STE 601, JACKSONVILLE, FL, 322242698, US | 6138 KENNERLY RD STE AND150, JACKSONVILLE, FL, 322164393, US | |||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 386-283-2010 |
Authorized person
| Name | TIFFANY HART |
| Role | CREDENTIALING/BILLING MANAGER |
| Phone | 9043007494 |
Taxonomy
| Taxonomy Code | 101YA0400X - Addiction (Substance Use Disorder) Counselor |
| Is Primary | No |
| Taxonomy Code | 101YM0800X - Mental Health Counselor |
| Is Primary | No |
| Taxonomy Code | 174H00000X - Health Educator |
| Is Primary | No |
| Taxonomy Code | 251B00000X - Case Management Agency |
| Is Primary | No |
| Taxonomy Code | 251E00000X - Home Health Agency |
| Is Primary | No |
| Taxonomy Code | 251S00000X - Community/Behavioral Health Agency |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2575228 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| GOODMAN ERAKAL | Agent | 4631 CAMP CREEK LANE, ORANGE PARK, FL, 32065 |
| Name | Role | Address |
|---|---|---|
| GOODMAN ERAKAL | Chief Executive Officer | 4631 CAMP CREEK LANE, ORANGE PARK, FL, 32065 |
| Name | Role | Address |
|---|---|---|
| HOWARD DYMAN | Vice President | 10453 GREENVILLE ROAD, JACKSONVILLE, FL, 32256 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2023-12-15 | 6138 Kennerly Road, Suite 150, JACKSONVILLE, FL 32216 | No data |
| CHANGE OF MAILING ADDRESS | 2022-09-15 | 6138 Kennerly Road, Suite 150, JACKSONVILLE, FL 32216 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-09 |
| ANNUAL REPORT | 2023-01-31 |
| AMENDED ANNUAL REPORT | 2022-01-11 |
| ANNUAL REPORT | 2022-01-03 |
| Domestic Non-Profit | 2021-02-04 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
