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  5. VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA

VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA

Company Details

Entity Name: VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Active
Date Filed: 14 Aug 2003 (21 years ago)
Last Event: REINSTATEMENT
Event Date Filed: 21 Oct 2021 (3 years ago)
Document Number: P03000089100
FEI/EIN Number 760739954
Address: 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162
Mail Address: 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162
ZIP code: 32162
County: Sumter
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1801939277 2007-02-15 2010-11-29 3351 WEDGEWOOD LN, THE VILLAGES, FL, 321627181, US 3351 WEDGEWOOD LN, THE VILLAGES, FL, 321627181, US

Contacts
Phone +1 352-259-0634
Fax 3522592174

Authorized person
Name DR. WINSTON EVALLE
Role PRESIDENT
Phone 3522590364

Taxonomy
Taxonomy Code 207R00000X - Internal Medicine Physician
License Number ME80483
State FL
Is Primary Yes
Taxonomy Code 207RG0300X - Geriatric Medicine (Internal Medicine) Physician
License Number ME80483
State FL
Is Primary No

Other Provider Identifiers
Issuer BLUE CROSS BLUE SHIELD
Number 58634
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2023 760739954 2024-10-28 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2024-10-28
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2022 760739954 2023-10-16 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2023-10-16
Name of individual signing WNSTON EVALLE MD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2023-10-16
Name of individual signing WNSTON EVALLE MD
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2021 760739954 2022-10-15 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2022-10-15
Name of individual signing WNSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2022-10-15
Name of individual signing WNSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2020 760739954 2021-10-13 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2021-10-13
Name of individual signing WNSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-10-13
Name of individual signing WNSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2019 760739954 2020-10-13 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 2
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2020-10-13
Name of individual signing WNSTON EVALLE MD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-10-13
Name of individual signing WNSTON EVALLE MD
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2018 760739954 2019-10-05 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2019-10-03
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-10-03
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2017 760739954 2018-10-03 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2018-10-03
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-10-03
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2016 760739954 2017-10-05 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2017-10-02
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-10-02
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2015 760739954 2016-06-13 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2016-06-08
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-06-08
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature
VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA RETIREMENT PLAN AND TRUST 2014 760739954 2015-07-29 VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC, PA 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 3522590364
Plan sponsor’s address 3351 WEDGEWOOD LANE, THE VILLAGES, FL, 32162

Signature of
Role Plan administrator
Date 2015-07-29
Name of individual signing WINSTON EVALLE
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
EVALLE WINSTON Agent 433 Sunnyside Drive, LEESBURG, FL, 34748

Manager

Name Role Address
EVALLE WINSTON Manager 433 Sunnyside Drive, LEESBURG, FL, 34748

Director

Name Role Address
EVALLE WINSTON Director 433 Sunnyside Drive, LEESBURG, FL, 34748

Secretary

Name Role Address
Cipriano Josephine G Secretary 433 Sunnyside Drive, LEESBURG, FL, 34748

Events

Event Type Filed Date Value Description
REINSTATEMENT 2021-10-21 No data No data
REGISTERED AGENT NAME CHANGED 2021-10-21 EVALLE, WINSTON No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2021-09-24 No data No data
REGISTERED AGENT ADDRESS CHANGED 2016-03-02 433 Sunnyside Drive, LEESBURG, FL 34748 No data
CHANGE OF MAILING ADDRESS 2009-02-02 3351 WEDGEWOOD LANE, THE VILLAGES, FL 32162 No data

Documents

Name Date
ANNUAL REPORT 2024-01-18
ANNUAL REPORT 2023-01-12
ANNUAL REPORT 2022-02-26
REINSTATEMENT 2021-10-21
ANNUAL REPORT 2020-03-30
ANNUAL REPORT 2019-03-19
ANNUAL REPORT 2018-04-02
ANNUAL REPORT 2017-02-17
ANNUAL REPORT 2016-03-02
ANNUAL REPORT 2015-02-24

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 01 Feb 2025

Sources: Florida Department of State

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