| Entity Name: | ILLUMINATE MENTAL HEALTH, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 23 Jan 2023 (2 years ago) |
| Document Number: | P23000007168 |
| FEI/EIN Number | 92-2037145 |
| Address: | 681 Box Branch Circle, JACKSONVILLE, FL, 32259, US |
| Mail Address: | 681 Box Branch Circle, JACKSONVILLE, FL, 32259, US |
| ZIP code: | 32259 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1720840846 | 2024-01-24 | 2024-01-24 | 681 BOX BRANCH CIR, ST JOHNS, FL, 322594379, US | 12627 SAN JOSE BLVD STE 301, JACKSONVILLE, FL, 322238639, US | |||||||||||||
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| Phone | +1 540-222-3495 |
Authorized person
| Name | MR. MATTHEW MEWHORTER |
| Role | VICE PRESIDENT/OFFICER |
| Phone | 5402223495 |
Taxonomy
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| MEWHORTER AMANDA M | Agent | 597 SPARROW BRANCH CIRCLE, JACKSONVILLE, FL, 32259 |
| Name | Role | Address |
|---|---|---|
| MEWHORTER AMANDA M | President | 681 Box Branch Circle, JACKSONVILLE, FL, 32259 |
| Name | Role | Address |
|---|---|---|
| MEWHORTER MATTHEW P | Vice President | 681 Box Branch Circle, JACKSONVILLE, FL, 32259 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-02-09 | 681 Box Branch Circle, JACKSONVILLE, FL 32259 | No data |
| CHANGE OF MAILING ADDRESS | 2024-02-09 | 681 Box Branch Circle, JACKSONVILLE, FL 32259 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-09 |
| Domestic Profit | 2023-01-23 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
