| Entity Name: | WEST VOLUSIA FAMILY AND SPORTS MEDICINE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 24 Feb 2010 (15 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 14 Oct 2016 (8 years ago) |
| Document Number: | P10000016803 |
| FEI/EIN Number | 271970908 |
| Address: | 1590 S SR 15A, DeLand, FL, 32720, US |
| Mail Address: | 1590 S SR 15A, DeLand, FL, 32720, US |
| ZIP code: | 32720 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1548584600 | 2010-03-18 | 2020-08-04 | PO BOX 23764, TAMPA, FL, 336233764, US | 742 N VOLUSIA AVE, ORANGE CITY, FL, 327634857, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 727-823-2188 |
| Fax | 7278280723 |
| Phone | +1 386-774-0016 |
Authorized person
| Name | JOHN HILL |
| Role | OWNER / PROVIDER |
| Phone | 3867740016 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | ME93242 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 002241400 |
| State | FL |
| Issuer | BCBS |
| Number | 000TF |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| WEST VOLUSIA 401(K) PLAN | 2023 | 274352136 | 2024-05-17 | WEST VOLUSIA FAMILY AND SPORTS MEDICINE | 38 | |||||||||||||||||||||||||||||||
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| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-17 |
| Name of individual signing | QIAN LIU |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2021-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 4074378871 |
| Plan sponsor’s address | 1590 STATE ROAD 15A, DELAND, FL, 32720 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1412 CHAPIN AVENUE, BURLINGAME, CA, 94010 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2023-05-27 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2021-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 4074378871 |
| Plan sponsor’s address | 1590 STATE ROAD 15A, DELAND, FL, 32720 |
Plan administrator’s name and address
| Administrator’s EIN | 474474775 |
| Plan administrator’s name | GUIDELINE, INC. |
| Plan administrator’s address | 1645 E 6TH STREET, SUITE 200, AUSTIN, TX, 78702 |
| Administrator’s telephone number | 8882283491 |
Signature of
| Role | Plan administrator |
| Date | 2022-06-02 |
| Name of individual signing | CHRISTINE RIMER |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| HILL JOHN | Agent | 1590 S SR 15A, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| HILL JOHN | President | 1590 S SR 15A, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| HILL JOHN | Director | 1590 S SR 15A, DeLand, FL, 32720 |
| Name | Role | Address |
|---|---|---|
| HILL JOHN | Secretary | 1590 S SR 15A, DeLand, FL, 32720 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2016-10-14 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-10-14 | HILL, JOHN | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2013-01-20 | 1590 S SR 15A, DeLand, FL 32720 | No data |
| CHANGE OF MAILING ADDRESS | 2013-01-20 | 1590 S SR 15A, DeLand, FL 32720 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2013-01-20 | 1590 S SR 15A, DeLand, FL 32720 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-07 |
| ANNUAL REPORT | 2023-01-30 |
| ANNUAL REPORT | 2022-04-21 |
| ANNUAL REPORT | 2021-04-06 |
| ANNUAL REPORT | 2020-05-06 |
| ANNUAL REPORT | 2019-03-25 |
| ANNUAL REPORT | 2018-03-19 |
| ANNUAL REPORT | 2017-03-10 |
| REINSTATEMENT | 2016-10-14 |
| ANNUAL REPORT | 2015-03-20 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
