| Entity Name: | SAMUEL WALTERS, D.O., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 26 Dec 2001 (23 years ago) |
| Date of dissolution: | 23 Sep 2022 (2 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 23 Sep 2022 (2 years ago) |
| Document Number: | P01000121193 |
| FEI/EIN Number | 010563833 |
| Address: | 6531 103RD ST., JACKSONVILLE, FL, 32210 |
| Mail Address: | 6531 103RD ST., JACKSONVILLE, FL, 32210 |
| ZIP code: | 32210 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1285966499 | 2010-02-12 | 2010-07-03 | 6531 103RD ST, JACKSONVILLE, FL, 322107131, US | 6531 103RD ST, JACKSONVILLE, FL, 322107131, US | |||||||||||||||||||||||||
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| Phone | +1 904-772-2727 |
| Fax | 9047721693 |
Authorized person
| Name | SAMUEL WALTERS |
| Role | CEO/PHYSICIAN |
| Phone | 9047722727 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| License Number | OS8337 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 261008600 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SAMUEL WALTERS D O P A 401 K PROFIT SHARING PLAN TRUST | 2017 | 010563833 | 2018-07-31 | SAMUEL WALTERS D O P A | 2 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2018-07-31 |
| Name of individual signing | SAMUEL WALTERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2010-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9047722727 |
| Plan sponsor’s address | 6531 103RD ST, JACKSONVILLE, FL, 322107131 |
Signature of
| Role | Plan administrator |
| Date | 2018-07-31 |
| Name of individual signing | SAMUEL WALTERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2010-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9047722727 |
| Plan sponsor’s address | 6531 103RD ST, JACKSONVILLE, FL, 322107131 |
Signature of
| Role | Plan administrator |
| Date | 2018-07-31 |
| Name of individual signing | SAMUEL WALTERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2010-01-01 |
| Business code | 621510 |
| Sponsor’s telephone number | 9047722727 |
| Plan sponsor’s address | 6531 103RD ST, JACKSONVILLE, FL, 322107131 |
Signature of
| Role | Plan administrator |
| Date | 2018-07-31 |
| Name of individual signing | SAMUEL WALTERS |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| WALTERS SAMUEL | Agent | 6531 103RD ST., JACKSONVILLE, FL, 32210 |
| Name | Role | Address |
|---|---|---|
| WALTERS SAMUEL | Director | 6531 103RD ST., JACKSONVILLE, FL, 32210 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| REINSTATEMENT | 2011-10-04 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2011-09-23 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2009-06-23 | 6531 103RD ST., JACKSONVILLE, FL 32210 | No data |
| CHANGE OF MAILING ADDRESS | 2009-06-23 | 6531 103RD ST., JACKSONVILLE, FL 32210 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2009-06-23 | 6531 103RD ST., JACKSONVILLE, FL 32210 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2021-04-24 |
| ANNUAL REPORT | 2020-06-13 |
| ANNUAL REPORT | 2019-04-28 |
| ANNUAL REPORT | 2018-04-29 |
| ANNUAL REPORT | 2017-04-01 |
| ANNUAL REPORT | 2016-07-16 |
| ANNUAL REPORT | 2015-04-25 |
| ANNUAL REPORT | 2014-02-01 |
| ANNUAL REPORT | 2013-03-02 |
| ANNUAL REPORT | 2012-03-22 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
