| Entity Name: | AMPUTEE CLINIC, INC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 01 Mar 2012 (13 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 05 Mar 2024 (a year ago) |
| Document Number: | P12000021025 |
| FEI/EIN Number | 45-4672954 |
| Address: | 7051 CYPRESS TERRACE #108, FORT MYERS, FL, 33907 |
| Mail Address: | 7051 CYPRESS TERRACE #108, FORT MYERS, FL, 33907 |
| ZIP code: | 33907 |
| County: | Lee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1295730216 | 2005-06-16 | 2012-08-30 | 7051 CYPRESS TER, #108, FORT MYERS, FL, 339078822, US | 7051 CYPRESS TER, #108, FORT MYERS, FL, 339078822, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 239-437-4010 |
| Fax | 2394374097 |
Authorized person
| Name | MR. MARCUM R RANDALL |
| Role | PRESIDENT PT CP LPO |
| Phone | 2394374010 |
Taxonomy
| Taxonomy Code | 261QP2000X - Physical Therapy Clinic/Center |
| Is Primary | No |
| Taxonomy Code | 335E00000X - Prosthetic/Orthotic Supplier |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 009939684 |
| State | AL |
| Issuer | NORTHWOOD (BC/BS MI DME) |
| Number | 81750 |
| State | MI |
| Issuer | TVA |
| Number | 204925600 |
| State | TN |
| Issuer | NORTHWOOD |
| Number | 8150 |
| State | MI |
| Issuer | MEDICAID |
| Number | 1454256 |
| State | TN |
| Issuer | GEORGIA HEALTH PARTNERSHI |
| Number | 52895744 001 |
| State | GA |
| Issuer | MEDICAID |
| Number | 1295730216 |
| State | VA |
| Issuer | MEDICAID |
| Number | 000914064A |
| State | GA |
| Issuer | BC/BS OF TN |
| Number | 004016999 |
| State | TN |
| Issuer | PHP, CARITEN, PHP TENNCAR |
| Number | 13125 |
| State | TN |
| Issuer | BC/BS TN |
| Number | 4016999 |
| State | TN |
| Name | Role | Address |
|---|---|---|
| HEAD WILLIAM CPA | Agent | 1845 SE 4 AVENUE, FT. LAUDERDALE, FL, 33316 |
| Name | Role | Address |
|---|---|---|
| RANDALL MARCUM R | President | 7051 CYPRESS TERRACE #108, FORT MYERS, FL, 33907 |
| Name | Role | Address |
|---|---|---|
| RANDALL MARCUM R | Treasurer | 7051 CYPRESS TERRACE #108, FORT MYERS, FL, 33907 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000063627 | ALL AMERICAN AMPUTEE | EXPIRED | 2014-06-20 | 2019-12-31 | No data | 7051 CYPRESS TERRACE #108, FORT MYERS, FL, 33907 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-03-05 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2023-09-22 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-04-15 | 1845 SE 4 AVENUE, FT. LAUDERDALE, FL 33316 | No data |
| REGISTERED AGENT NAME CHANGED | 2013-04-25 | HEAD, WILLIAM, CPA | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2012-07-19 | 7051 CYPRESS TERRACE #108, FORT MYERS, FL 33907 | No data |
| CHANGE OF MAILING ADDRESS | 2012-07-19 | 7051 CYPRESS TERRACE #108, FORT MYERS, FL 33907 | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J13001490615 | TERMINATED | 1000000536198 | LEE | 2013-09-17 | 2033-10-03 | $ 300.00 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, FORT MYERS SERVICE CENTER, 2295 VICTORIA AVE STE 270, FORT MYERS FL339013871 |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-03-05 |
| ANNUAL REPORT | 2022-04-22 |
| ANNUAL REPORT | 2021-03-22 |
| ANNUAL REPORT | 2020-01-23 |
| ANNUAL REPORT | 2019-02-08 |
| ANNUAL REPORT | 2018-04-17 |
| ANNUAL REPORT | 2017-04-25 |
| ANNUAL REPORT | 2016-04-15 |
| ANNUAL REPORT | 2015-04-21 |
| ANNUAL REPORT | 2014-04-06 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
