| Entity Name: | FORMOSO PAIN SPECIALISTS, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 13 May 2020 (5 years ago) |
| Document Number: | P20000036314 |
| FEI/EIN Number | 85-1148402 |
| Address: | 4472 GLEN KERNAN PKWY E, JACKSONVILLE, FL 32224 |
| Mail Address: | 4472 GLEN KERNAN PKWY E, JACKSONVILLE, FL 32224 |
| ZIP code: | 32224 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1578224135 | 2022-01-06 | 2022-01-06 | 11555 CENTRAL PKWY STE 304, JACKSONVILLE, FL, 322242694, US | 11555 CENTRAL PKWY STE 304, JACKSONVILLE, FL, 322242694, US | |||||||||||||
|
|||||||||||||||||
| Phone | +1 904-650-2963 |
Authorized person
| Name | FERDINAND JOSEPH FORMOSO |
| Role | OWNER |
| Phone | 9045882393 |
Taxonomy
| Taxonomy Code | 261QP3300X - Pain Clinic/Center |
| Is Primary | Yes |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FORMOSO PAIN SPECIALISTS PA 401(K) PROFIT SHARING PLAN & TRUST | 2023 | 851148402 | 2024-05-03 | FORMOSO PAIN SPECIALISTS PA | 16 | |||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||
| Administrator’s EIN | 471637791 |
| Plan administrator’s name | ERISA FIDUCIARY SERVICES, INC. |
| Plan administrator’s address | 1373 VETERANS HIGHWAY, SUITE 10, HAUPPAUGE, NY, 11788 |
| Administrator’s telephone number | 6312490500 |
Signature of
| Role | Plan administrator |
| Date | 2024-05-03 |
| Name of individual signing | ERISA FIDUCIARY SERVICES |
| 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 | 621111 |
| Sponsor’s telephone number | 9049237897 |
| Plan sponsor’s address | 11555 CENTRAL PARKWAY SUITE 304, JACKSONVILLE, FL, 32224 |
Plan administrator’s name and address
| Administrator’s EIN | 471637791 |
| Plan administrator’s name | ERISA FIDUCIARY SERVICES, INC. |
| Plan administrator’s address | 1373 VETERANS HIGHWAY, SUITE 10, HAUPPAUGE, NY, 11788 |
| Administrator’s telephone number | 6312490500 |
Signature of
| Role | Plan administrator |
| Date | 2023-04-08 |
| Name of individual signing | ERISA FIDUCIARY SERVICES |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| DuVal Fields CPA Group, PA | Agent | 428 WALNUT STREET, GREEN COVE SPRINGS, FL 32043 |
| Name | Role | Address |
|---|---|---|
| FORMOSO, FERDINAND | President | 4472 GLEN KERNAN PKWY E, JACKSONVILLE, FL 32224 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G24000086134 | BOLD CITY CLINICAL RESEARCH | ACTIVE | 2024-07-18 | 2029-12-31 | No data | 11555 CENTRAL PARKWAY, SUITE 304, JACKSONVILLE, FL, 32224 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-04-02 | DuVal Fields CPA Group, PA | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-04-14 | 428 WALNUT STREET, GREEN COVE SPRINGS, FL 32043 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-02 |
| ANNUAL REPORT | 2023-02-15 |
| ANNUAL REPORT | 2022-04-12 |
| AMENDED ANNUAL REPORT | 2021-04-14 |
| ANNUAL REPORT | 2021-03-17 |
| Domestic Profit | 2020-05-13 |
Date of last update: 16 Jan 2025
Sources: Florida Department of State
