| Entity Name: | MINDBLOOM PROVIDER GROUP, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 14 May 2019 (6 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 25 Mar 2021 (4 years ago) |
| Document Number: | P19000040303 |
| FEI/EIN Number | 84-2207855 |
| Address: | 7901 4TH ST N, STE 300, ST. PETERSBURG, FL 33702 |
| Mail Address: | 1317 Edgewater Dr, #1583, Orlando, FL 32804 |
| ZIP code: | 33702 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| Type | Company Name | Company Number | State |
|---|---|---|---|
| Headquarter of | MINDBLOOM PROVIDER GROUP, P.A., ALASKA | 10182761 | ALASKA |
| Headquarter of | MINDBLOOM PROVIDER GROUP, P.A., NEW YORK | 5875068 | NEW YORK |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MINDBLOOM PROVIDER GROUP 401(K) PLAN | 2023 | 842207855 | 2024-07-29 | MINDBLOOM PROVIDER GROUP, P.A. | 8 | |||||||||||||||||||||||
|
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| Role | Plan administrator |
| Date | 2024-07-29 |
| Name of individual signing | GRIFFIN CHASE |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2022-01-01 |
| Business code | 621112 |
| Plan sponsor’s address | 1317 EDGEWATER DR., #1583, ORLANDO, FL, 32804 |
Signature of
| Role | Plan administrator |
| Date | 2023-07-25 |
| Name of individual signing | GRIFFIN CHASE |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role |
|---|---|
| NORTHWEST REGISTERED AGENT LLC | Agent |
| Name | Role | Address |
|---|---|---|
| VANDO, LEONARDO, MD | P D | 1317 Edgewater Dr, #1583 Orlando, FL 32804 |
| Name | Role | Address |
|---|---|---|
| SWAIN, JACK | Chief Administrative Officer | 1317 Edgewater Dr, #1583 Orlando, FL 32804 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2021-03-25 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-03-25 | 7901 4TH ST N, STE 300, ST. PETERSBURG, FL 33702 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-02-10 | NORTHWEST REGISTERED AGENT LLC | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-02-10 | 7901 4TH ST N STE 300, ST. PETERSBURG, FL 33702 | No data |
| CHANGE OF MAILING ADDRESS | 2020-10-12 | 7901 4TH ST N, STE 300, ST. PETERSBURG, FL 33702 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-02-17 |
| ANNUAL REPORT | 2022-02-22 |
| ANNUAL REPORT | 2021-03-31 |
| Amendment | 2021-03-25 |
| Reg. Agent Change | 2021-02-10 |
| Reg. Agent Change | 2020-09-30 |
| ANNUAL REPORT | 2020-03-05 |
| Domestic Profit | 2019-05-14 |
Date of last update: 16 Feb 2025
Sources: Florida Department of State
