| Entity Name: | BLAINE PAYNE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 20 May 2014 (11 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 19 Feb 2024 (a year ago) |
| Document Number: | P14000045295 |
| FEI/EIN Number | 47-1029812 |
| Address: | 180 NW HAYNES STREET, MADISON, FL, 32340, US |
| Mail Address: | P.O. BOX 185, MADISON, FL, 32341, US |
| ZIP code: | 32340 |
| County: | Madison |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1770943409 | 2016-02-23 | 2016-06-30 | PO BOX 185, MADISON, FL, 323410185, US | 180 NW HAYNES ST, MADISON, FL, 323402010, US | |||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 850-973-1215 |
| Fax | 8669234163 |
Authorized person
| Name | TAMMEY REVELS |
| Role | BUSINESS MANAGER |
| Phone | 8509731215 |
Taxonomy
| Taxonomy Code | 207QG0300X - Geriatric Medicine (Family Medicine) Physician |
| License Number | OS9255 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 37137 |
| Issuer | MEDICAID |
| Number | 272752800 |
| State | FL |
| Issuer | HUMANA |
| Number | HUMANA |
| Issuer | BCBS |
| Number | SXJQY |
| Name | Role | Address |
|---|---|---|
| Ball Angela M | Agent | 615 N. JEFFERSON ST., PERRY, FL, 32347 |
| Name | Role | Address |
|---|---|---|
| PAYNE THERESA B | President | Post Office Box 185, Madison, FL, 32341 |
| Name | Role | Address |
|---|---|---|
| PAYNE THERESA B | Treasurer | Post Office Box 185, Madison, FL, 32341 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-02-19 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2024-02-19 | Ball, Angela M. | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2023-09-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-02-16 | 180 NW HAYNES STREET, MADISON, FL 32340 | No data |
| CHANGE OF MAILING ADDRESS | 2016-02-16 | 180 NW HAYNES STREET, MADISON, FL 32340 | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-02-19 |
| ANNUAL REPORT | 2022-03-24 |
| ANNUAL REPORT | 2021-04-19 |
| ANNUAL REPORT | 2020-03-19 |
| ANNUAL REPORT | 2019-04-26 |
| ANNUAL REPORT | 2018-04-30 |
| ANNUAL REPORT | 2017-04-26 |
| ANNUAL REPORT | 2016-04-28 |
| ANNUAL REPORT | 2015-04-28 |
| Domestic Profit | 2014-05-20 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
