| Entity Name: | QUINCY FAMILY MEDICINE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 02 May 2000 (25 years ago) |
| Last Event: | CANCEL ADM DISS/REV |
| Event Date Filed: | 29 Aug 2008 (16 years ago) |
| Document Number: | P00000044516 |
| FEI/EIN Number | 593643388 |
| Address: | 10143 Moccasin Gap Road, Tallahassee, FL, 32309, US |
| Mail Address: | POB 13621, Tallahassee, FL, 32317, US |
| ZIP code: | 32309 |
| County: | Leon |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386812915 | 2008-02-17 | 2009-02-17 | 300 E JEFFERSON ST, QUINCY, FL, 323512530, US | 300 E JEFFERSON ST, QUINCY, FL, 323512530, US | |||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-875-1146 |
| Fax | 8508751218 |
Authorized person
| Name | DR. CARLA MONICA HOLLOMAN |
| Role | PHYSICIAN/OWNER |
| Phone | 8508751146 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | OS 0007688 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICARE GROUP |
| Number | K1831 |
| State | FL |
| Issuer | HEALTHEASE |
| Number | 167177 |
| State | FL |
| Issuer | MEDICAID |
| Number | 255092000 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 44300 |
| State | FL |
| Issuer | VISTA HEALTHPLAN |
| Number | 069578 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| HOLLOMAN CARLA M | Agent | 10143 Moccasin Gap Road, Tallahassee, FL, 32309 |
| Name | Role | Address |
|---|---|---|
| HOLLOMAN CARLA M | President | POB 13621, Tallahassee, FL, 32317 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2022-04-30 | 10143 Moccasin Gap Road, Tallahassee, FL 32309 | No data |
| CHANGE OF MAILING ADDRESS | 2022-04-30 | 10143 Moccasin Gap Road, Tallahassee, FL 32309 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-04-30 | 10143 Moccasin Gap Road, Tallahassee, FL 32309 | No data |
| CANCEL ADM DISS/REV | 2008-08-29 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2008-08-29 | HOLLOMAN, CARLA MD.O. | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2002-10-04 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-29 |
| ANNUAL REPORT | 2023-04-28 |
| ANNUAL REPORT | 2022-04-30 |
| ANNUAL REPORT | 2021-04-30 |
| ANNUAL REPORT | 2020-06-07 |
| ANNUAL REPORT | 2019-04-30 |
| ANNUAL REPORT | 2018-04-24 |
| ANNUAL REPORT | 2017-04-08 |
| ANNUAL REPORT | 2016-04-19 |
| ANNUAL REPORT | 2015-04-22 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
