| Entity Name: | THREE RIVERS MEDICAL, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 21 May 2003 (22 years ago) |
| Date of dissolution: | 22 May 2017 (8 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 22 May 2017 (8 years ago) |
| Document Number: | P03000056459 |
| FEI/EIN Number | 010783690 |
| Address: | 208 NW SUWANNEE AVENUE, BRANFORD, FL, 32008, US |
| Mail Address: | 29274 RIVER RUN ROAD, BRANFORD, FL, 32008, US |
| ZIP code: | 32008 |
| County: | Suwannee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1710049671 | 2006-12-15 | 2010-02-04 | 208 SUWANNEE AVE NW, BRANFORD, FL, 320083265, US | 208 SUWANNEE AVE NW, BRANFORD, FL, 320083265, US | |||||||||||||||||||||||||
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| Phone | +1 386-935-1607 |
| Fax | 3869351667 |
Authorized person
| Name | MS. PEGGY L MALONEY |
| Role | PRACTICE MANAGER |
| Phone | 3869351607 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | 2934442 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 303822000 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| THREE RIVERS MEDICAL 401(K) P/S PLAN | 2012 | 010783690 | 2013-07-24 | THREE RIVERS MEDICAL | 8 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 010783690 |
| Plan administrator’s name | THREE RIVERS MEDICAL |
| Plan administrator’s address | 208 NW SUWANNEE AVE, BRANFORD, FL, 32008 |
| Administrator’s telephone number | 3869351607 |
Signature of
| Role | Plan administrator |
| Date | 2013-07-24 |
| Name of individual signing | RODNEY SCYPHERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2009-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3869351607 |
| Plan sponsor’s address | 208 NW SUWANNEE AVE, BRANFORD, FL, 32008 |
Plan administrator’s name and address
| Administrator’s EIN | 010783690 |
| Plan administrator’s name | THREE RIVERS MEDICAL |
| Plan administrator’s address | 208 NW SUWANNEE AVE, BRANFORD, FL, 32008 |
| Administrator’s telephone number | 3869351607 |
Signature of
| Role | Plan administrator |
| Date | 2012-09-15 |
| Name of individual signing | MARGARET MALONEY |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2009-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3869351607 |
| Plan sponsor’s address | 208 NW SUWANNEE AVE, BRANFORD, FL, 32008 |
Plan administrator’s name and address
| Administrator’s EIN | 010783690 |
| Plan administrator’s name | THREE RIVERS MEDICAL |
| Plan administrator’s address | 208 NW SUWANNEE AVE, BRANFORD, FL, 32008 |
| Administrator’s telephone number | 3869351607 |
Signature of
| Role | Plan administrator |
| Date | 2011-10-10 |
| Name of individual signing | MARGARET MALONEY |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2009-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 3869351607 |
| Plan sponsor’s address | 208 NW SUWANNEE AVE, BRANDFORD, FL, 32008 |
Plan administrator’s name and address
| Administrator’s EIN | 010783690 |
| Plan administrator’s name | THREE RIVERS MEDICAL |
| Plan administrator’s address | 208 NW SUWANNEE AVE, BRANDFORD, FL, 32008 |
| Administrator’s telephone number | 3869351607 |
Signature of
| Role | Plan administrator |
| Date | 2010-06-24 |
| Name of individual signing | MARGARET MALONEY |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| SCYPHERS RODNEY | Agent | 29274 RIVER RUN ROAD, BRANFORD, FL, 32008 |
| Name | Role | Address |
|---|---|---|
| SCYPHERS RODNEY | Vice President | 29274 RIVER RUN ROAD, BRANFORD, FL, 32008 |
| Dr. Michel Vandormael | Vice President | 9525 Blind Pass Rd, St. Pete Beach, FL, 33706 |
| Name | Role | Address |
|---|---|---|
| Dr. Moise Anglade | President | 1483 South Federal Hwy, Boynton Beach, FL, 33435 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2017-05-22 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2013-07-09 | SCYPHERS, RODNEY | No data |
| AMENDMENT | 2007-06-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2005-01-11 | 208 NW SUWANNEE AVENUE, BRANFORD, FL 32008 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2017-04-08 |
| ANNUAL REPORT | 2016-04-23 |
| ANNUAL REPORT | 2015-01-09 |
| ANNUAL REPORT | 2014-04-15 |
| AMENDED ANNUAL REPORT | 2013-08-05 |
| ANNUAL REPORT | 2013-07-09 |
| ANNUAL REPORT | 2012-01-05 |
| ANNUAL REPORT | 2011-01-06 |
| ANNUAL REPORT | 2010-07-15 |
| ANNUAL REPORT | 2009-01-18 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
