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  5. CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC.

CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC.

Company Details

Entity Name: CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC.
Jurisdiction: FLORIDA
Filing Type: Florida Not For Profit Corporation
Status: Active
Date Filed: 21 Feb 1991 (34 years ago)
Last Event: CANCEL ADM DISS/REV
Event Date Filed: 20 Dec 2005 (19 years ago)
Document Number: N42167
FEI/EIN Number 59-3051173
Address: 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424
Mail Address: 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424
ZIP code: 32424
County: Calhoun
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1588944334 2011-08-25 2024-10-18 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045, US 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045, US

Contacts
Phone +1 850-674-5411
Fax 8506743550

Authorized person
Name EMILY MARLO BROWN
Role CHIEF EXECUTIVE OFFICER
Phone 8506745411

Taxonomy
Taxonomy Code 261QP2300X - Primary Care Clinic/Center
License Number HCC680
State FL
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
CALHOUN LIBERTY HOSPITAL HUMANA LIFE INSURANCE 2018 539051173 2019-05-13 CALHOUN LIBERTY HOSPITAL ASSOCIATION 92
File View Page
Three-digit plan number (PN) 503
Effective date of plan 2018-02-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN LIBERTY HOSPITAL
Plan sponsor’s mailing address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045
Plan sponsor’s address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045

Number of participants as of the end of the plan year
Active participants 92

Signature of
Role Plan administrator
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
CALHOUN LIBERTY HOSPITAL HUMANA LIFE INSURANCE 2017 593051173 2019-05-13 CALHOUN LIBERTY HOSPITAL ASSOCIATION INC 109
File View Page
Three-digit plan number (PN) 503
Effective date of plan 2017-02-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN LIBERTY HOSPITAL
Plan sponsor’s mailing address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045
Plan sponsor’s address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045

Number of participants as of the end of the plan year
Active participants 109

Signature of
Role Plan administrator
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
CALHOUN LIBERTY HOSPITAL HUMANA LIFE INSURANCE 2017 593051173 2019-05-13 CALHOUN LIBERTY HOSPITAL ASSOCIATION INC 109
Three-digit plan number (PN) 503
Effective date of plan 2017-02-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN LIBERTY HOSPITAL
Plan sponsor’s mailing address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045
Plan sponsor’s address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045

Number of participants as of the end of the plan year
Active participants 109

Signature of
Role Plan administrator
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
CALHOUN LIBERTY HOSPITAL HUMANA LIFE INSURANCE 2016 593051173 2019-05-13 CALHOUN LIBERTY HOSPITAL ASSOCIATION INC 107
File View Page
Three-digit plan number (PN) 503
Effective date of plan 2016-02-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN LIBERTY HOSPITAL
Plan sponsor’s mailing address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045
Plan sponsor’s address 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 324241045

Number of participants as of the end of the plan year
Active participants 109
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 0

Signature of
Role Plan administrator
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-13
Name of individual signing CHARLES STEWARD
Valid signature Filed with authorized/valid electronic signature
CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 401(K) PLAN 2010 593051173 2011-07-20 CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 80
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-11-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s address 20370 NORTHEAST BURNS AVE, BOX 419, BLOUNTSTOWN, FL, 32424

Plan administrator’s name and address
Administrator’s EIN 593051173
Plan administrator’s name CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC.
Plan administrator’s address 20370 NORTHEAST BURNS AVE, BOX 419, BLOUNTSTOWN, FL, 32424
Administrator’s telephone number 8506745411

Signature of
Role Plan administrator
Date 2011-07-20
Name of individual signing NATHAN EBERSOLE
Valid signature Filed with authorized/valid electronic signature
CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 401(K) PLAN 2009 593051173 2011-01-03 CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC. 98
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-11-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s address 20370 NORTHEAST BURNS AVE. BOX 419, BLOUNTSTOWN, FL, 32424

Plan administrator’s name and address
Administrator’s EIN 593051173
Plan administrator’s name CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC.
Plan administrator’s address 20370 NORTHEAST BURNS AVE. BOX 419, BLOUNTSTOWN, FL, 32424
Administrator’s telephone number 8506745411

Signature of
Role Plan administrator
Date 2011-01-03
Name of individual signing NATHAN EBERSOLE
Valid signature Filed with authorized/valid electronic signature
CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 401(K) PLAN 2009 593051173 2010-12-29 CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC. 98
Three-digit plan number (PN) 001
Effective date of plan 2007-11-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s address 20370 NORTHEAST BURNS AVE. BOX 419, BLOUNTSTOWN, FL, 32424

Plan administrator’s name and address
Administrator’s EIN 593051173
Plan administrator’s name CALHOUN-LIBERTY HOSPITAL ASSOCIATION, INC.
Plan administrator’s address 20370 NORTHEAST BURNS AVE. BOX 419, BLOUNTSTOWN, FL, 32424
Administrator’s telephone number 8506745411
CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 2009 593051173 2010-09-24 CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 7
Three-digit plan number (PN) 001
Effective date of plan 2007-11-01
Business code 940733
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN - LIBERTY HOSPITAL
Plan sponsor’s address 20370 NORTHEAST BURNS AVE., P.O. BOX 419, BLOUNTSTOWN, FL, 32424

Plan administrator’s name and address
Administrator’s EIN 593051173
Plan administrator’s name CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC.
Plan administrator’s address 20370 NORTHEAST BURNS AVE., P.O. BOX 419, BLOUNTSTOWN, FL, 32424
Administrator’s telephone number 8506745411

Signature of
Role Plan administrator
Date 2010-09-24
Name of individual signing NATHAN EBERSOLE
Valid signature Filed with authorized/valid electronic signature
CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 2009 593051173 2010-09-27 CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC. 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-11-01
Business code 622000
Sponsor’s telephone number 8506745411
Plan sponsor’s DBA name CALHOUN - LIBERTY HOSPITAL
Plan sponsor’s address 20370 NORTHEAST BURNS AVE., P.O. BOX 419, BLOUNTSTOWN, FL, 32424

Plan administrator’s name and address
Administrator’s EIN 593051173
Plan administrator’s name CALHOUN - LIBERTY HOSPITAL ASSOCIATION, INC.
Plan administrator’s address 20370 NORTHEAST BURNS AVE., P.O. BOX 419, BLOUNTSTOWN, FL, 32424
Administrator’s telephone number 8506745411

Signature of
Role Plan administrator
Date 2010-09-27
Name of individual signing NATHAN EBERSOLE
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Brown, Emily Agent 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

Director

Name Role Address
WILLIAMS, LADDIE Director 17371 NW 5TH STREET, BLOUNTSTOWN, FL 32424
BONTRAGER, LABAN DMD Director 12799 NW PEA RIDGE RD, BRISTOL, FL 32321
Eubanks, Terry Director 11066 NW Lake Mystic Duggar Rd., Bristol, FL 32321
NEVES, MARY SUE Director PO BOX 53, BLOUNTSTOWN, FL 32424
FAUROT, MELBA Director 18310 NE ROY GOLDEN RD, BLOUNTSTOWN, FL 32424

Secretary

Name Role Address
RUSSELL, MARILYN Secretary 19306 NE JOHN G. BRYANT RD, BLOUNTSTOWN, FL 32424

Chairman

Name Role Address
PLUMMER, MARK Chairman 16059 NW LAKESIDE LANE, BRISTOL, FL 32321

Treasurer

Name Role Address
TOMLINSON, JOHN JR. Treasurer 20007 NE HENTZ AVE., BLOUNTSTOWN, FL 32424

Vice Chairman

Name Role Address
Revell, Tim Vice Chairman 17444 NW CR 379-A, Bristol, FL 32321

Chief Financial Officer

Name Role Address
Windham, Vann Chief Financial Officer 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

Chief Executive Officer

Name Role Address
Brown, Emily Chief Executive Officer 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

CNO

Name Role Address
Tolley, Paige CNO 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G12000032276 CALHOUN - LIBERTY PRIMARY CARE CLINIC ACTIVE 2012-04-03 2027-12-31 No data 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 32424
G07037900214 CALHOUN-LIBERTY HOSPITAL ACTIVE 2007-02-06 2027-12-31 No data 20370 NE BURNS AVE, BLOUNTSTOWN, FL, 32424

Events

Event Type Filed Date Value Description
CHANGE OF MAILING ADDRESS 2024-07-02 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424 No data
REGISTERED AGENT NAME CHANGED 2024-07-02 Brown, Emily No data
REGISTERED AGENT ADDRESS CHANGED 2011-07-21 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424 No data
CANCEL ADM DISS/REV 2005-12-20 No data No data
CHANGE OF PRINCIPAL ADDRESS 2005-12-20 20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424 No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2004-10-01 No data No data
REINSTATEMENT 2002-03-15 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2001-09-21 No data No data
REINSTATEMENT 1998-11-25 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 1998-10-16 No data No data

Documents

Name Date
AMENDED ANNUAL REPORT 2024-10-04
AMENDED ANNUAL REPORT 2024-07-02
AMENDED ANNUAL REPORT 2024-03-08
ANNUAL REPORT 2024-01-30
ANNUAL REPORT 2023-01-23
ANNUAL REPORT 2022-02-18
ANNUAL REPORT 2021-03-24
ANNUAL REPORT 2020-07-01
ANNUAL REPORT 2019-01-31
ANNUAL REPORT 2018-03-13

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Related by address

20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

CLH QALICB, INC.

20370 NE BURNS AVENUE, BLOUNTSTOWN, FL 32424

CLH QALICB, INC.

Date of last update: 03 Feb 2025

Sources: Florida Department of State

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