| Entity Name: | OKALOOSA MENTAL HEALTH AND PSYCHIATRIC CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 15 Oct 2003 (21 years ago) |
| Date of dissolution: | 22 Sep 2017 (7 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 22 Sep 2017 (7 years ago) |
| Document Number: | P03000113888 |
| FEI/EIN Number | 582678372 |
| Address: | 101 S. JEFFERSON STREET, SUITE C, PENSACOLA, FL, 32502, US |
| Mail Address: | P.O. BOX 12306, PENSACOLA, FL, 32591, US |
| ZIP code: | 32502 |
| County: | Escambia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1699970962 | 2007-06-18 | 2012-03-05 | 101 S JEFFERSON ST, SUITE C, PENSACOLA, FL, 325025656, US | 101 S JEFFERSON ST, SUITE C, PENSACOLA, FL, 325025656, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-432-3334 |
| Fax | 8504323353 |
Authorized person
| Name | DR. KIUMARS SHAMS |
| Role | EXECUTIVE MEDICAL DIRECTOR |
| Phone | 8504323334 |
Taxonomy
| Taxonomy Code | 2084A0401X - Addiction Medicine (Psychiatry & Neurology) Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084N0402X - Neurology with Special Qualifications in Child Neurology Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P0005X - Neurodevelopmental Disabilities Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 2084P0802X - Addiction Psychiatry Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P0804X - Child & Adolescent Psychiatry Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P0805X - Geriatric Psychiatry Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 2084P2900X - Pain Medicine (Psychiatry & Neurology) Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 208U00000X - Clinical Pharmacology Physician |
| License Number | ME29949 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BC BS FL |
| Number | 79178 |
| State | FL |
| Issuer | MEDICAID |
| Number | 038295700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHAMS KIUMARS E | Agent | 101 S. JEFFERSON STREET, PENSACOLA, FL, 32502 |
| Name | Role | Address |
|---|---|---|
| SHAMS KIUMARS E | President | 101 S. JEFFERSON ST., SUITE C, PENSACOLA, FL, 32502 |
| Name | Role | Address |
|---|---|---|
| SHAMS KIUMARS E | Secretary | 101 S. JEFFERSON ST., SUITE C, PENSACOLA, FL, 32502 |
| Name | Role | Address |
|---|---|---|
| SHAMS KIUMARS E | Treasurer | 101 S. JEFFERSON ST., SUITE C, PENSACOLA, FL, 32502 |
| Name | Role | Address |
|---|---|---|
| SHAMS KIUMARS E | Director | 101 S. JEFFERSON ST., SUITE C, PENSACOLA, FL, 32502 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000032956 | ESCAMBIA NEUROPSYCHIATRIC CENTER | EXPIRED | 2011-04-02 | 2016-12-31 | No data | P. O. BOX 12306, PENSACOLA, FL, 32591 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2017-09-22 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-01-30 | 101 S. JEFFERSON STREET, SUITE C, PENSACOLA, FL 32502 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-01-30 | 101 S. JEFFERSON STREET, SUITE C, PENSACOLA, FL 32502 | No data |
| CHANGE OF MAILING ADDRESS | 2012-01-30 | 101 S. JEFFERSON STREET, SUITE C, PENSACOLA, FL 32502 | No data |
| REGISTERED AGENT NAME CHANGED | 2012-01-30 | SHAMS, KIUMARS E | No data |
| REINSTATEMENT | 2011-01-03 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2010-09-24 | No data | No data |
| CANCEL ADM DISS/REV | 2006-10-11 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2006-09-15 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2016-03-27 |
| ANNUAL REPORT | 2015-04-24 |
| ANNUAL REPORT | 2014-03-21 |
| ANNUAL REPORT | 2013-02-27 |
| ANNUAL REPORT | 2012-01-30 |
| REINSTATEMENT | 2011-01-03 |
| ANNUAL REPORT | 2009-04-15 |
| ANNUAL REPORT | 2008-07-10 |
| ANNUAL REPORT | 2007-05-30 |
| REINSTATEMENT | 2006-10-11 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
