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  5. BREVARD ORTHOPAEDIC, SPINE & PAIN CLINIC, INC.

BREVARD ORTHOPAEDIC, SPINE & PAIN CLINIC, INC.

Company Details

Entity Name: BREVARD ORTHOPAEDIC, SPINE & PAIN CLINIC, INC.
Jurisdiction: FLORIDA
Filing Type: Florida Profit Corporation
Status: Inactive
Date Filed: 29 Sep 1995 (29 years ago)
Date of dissolution: 22 Sep 2023 (a year ago)
Last Event: ADMIN DISSOLUTION FOR ANNUAL REPORT
Event Date Filed: 22 Sep 2023 (a year ago)
Document Number: P95000075234
FEI/EIN Number 59-3345600
Address: 2222 S HARBOR CITY BLVD., SUITE 610, MELBOURNE, FL 32901
Mail Address: 2222 S HARBOR CITY BLVD., SUITE 610, MELBOURNE, FL 32901
ZIP code: 32901
County: Brevard
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1003100504 2011-06-02 2021-07-15 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015594, US 2222 S HARBOR CITY BLVD, SUITE 530, MELBOURNE, FL, 329015594, US

Contacts
Phone +1 321-723-7716
Fax 3217230604

Authorized person
Name KATRINA LOPEZ
Role CREDENTIALING
Phone 3215411537

Taxonomy
Taxonomy Code 111N00000X - Chiropractor
Is Primary No
Taxonomy Code 225100000X - Physical Therapist
Is Primary Yes
Taxonomy Code 225700000X - Massage Therapist
Is Primary No

Other Provider Identifiers
Issuer MEDICARE
Number 99949
State FL
Issuer MEDICAID
Number 040225700
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
THE B. A. C. K. CENTER 401(K) PLAN 2022 593345600 2023-02-28 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 119
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591
THE B. A. C. K. CENTER 401(K) PLAN 2021 593345600 2022-07-26 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 87
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591
THE B. A. C. K. CENTER 401(K) PLAN 2020 593345600 2021-08-26 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 77
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591
THE B.A.C.K. CENTER 401(K) PLAN 2019 593345600 2020-04-18 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 79
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591

Signature of
Role Plan administrator
Date 2020-04-18
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-04-18
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2018 593345600 2019-07-05 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 78
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591

Signature of
Role Plan administrator
Date 2019-07-05
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-07-05
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2017 593345600 2018-05-30 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 70
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591

Signature of
Role Plan administrator
Date 2018-05-30
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-05-30
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2016 593345600 2017-07-20 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 57
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591

Signature of
Role Plan administrator
Date 2017-07-20
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-07-20
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2015 593345600 2016-06-30 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 75
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 329015591

Signature of
Role Plan administrator
Date 2016-06-30
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-06-30
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2014 593345600 2015-07-29 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 78
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2200 FRONT ST STE 200, MELBOURNE, FL, 329017500

Signature of
Role Plan administrator
Date 2015-07-29
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2015-07-29
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
THE B.A.C.K. CENTER 401(K) PLAN 2013 593345600 2014-06-06 BREVARD ORTHOPAEDIC SPINE & PAIN CLINIC, INC. 76
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-07-15
Business code 621111
Sponsor’s telephone number 3217237716
Plan sponsor’s address 2200 FRONT ST STE 200, MELBOURNE, FL, 329017500

Signature of
Role Plan administrator
Date 2014-06-06
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2014-06-06
Name of individual signing BRENDA NEIDLINGER
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
HYNES, RICHARD A, MD Agent 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL 32901

Director

Name Role Address
HYNES, RICHARD A, MD Director 2222 S HARBOR CITY BLVD SUITE 610, MELBOURNE, FL 32901
DATTA, DEVIN K, MD Director 2222 S HARBOR CITY BLVD SUITE 610, MELBOURNE, FL 32901

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G19000101335 THE BACK CENTER EXPIRED 2019-09-16 2024-12-31 No data 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 32901
G14000124381 THE B.A.C.K. CENTER ACTIVE 2014-12-11 2025-12-31 No data 2222 S HARBOR CITY BLVD, SUITE 530, MELBOURNE, FL, 32901
G09000164507 DR. JAVA GOURMET CAFE EXPIRED 2009-10-13 2024-12-31 No data 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL, 32901

Events

Event Type Filed Date Value Description
ADMIN DISSOLUTION FOR ANNUAL REPORT 2023-09-22 No data No data
REGISTERED AGENT NAME CHANGED 2017-04-06 HYNES, RICHARD A, MD No data
CHANGE OF MAILING ADDRESS 2012-01-26 2222 S HARBOR CITY BLVD., SUITE 610, MELBOURNE, FL 32901 No data
CHANGE OF PRINCIPAL ADDRESS 2009-04-16 2222 S HARBOR CITY BLVD., SUITE 610, MELBOURNE, FL 32901 No data
REGISTERED AGENT ADDRESS CHANGED 2009-04-16 2222 S HARBOR CITY BLVD, SUITE 610, MELBOURNE, FL 32901 No data
NAME CHANGE AMENDMENT 2003-04-23 BREVARD ORTHOPAEDIC, SPINE & PAIN CLINIC, INC. No data
CORPORATE MERGER 1996-03-19 No data CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. CORPORATE MERGER NUMBER 300000009593
NAME CHANGE AMENDMENT 1995-10-26 BREVARD ORTHOPAEDIC CLINIC, INC. No data
CORPORATE MERGER 1995-10-05 No data CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. CORPORATE MERGER NUMBER 900000007429

Documents

Name Date
ANNUAL REPORT 2022-04-05
ANNUAL REPORT 2021-04-19
ANNUAL REPORT 2020-03-21
ANNUAL REPORT 2019-04-01
ANNUAL REPORT 2018-04-06
ANNUAL REPORT 2017-04-06
Off/Dir Resignation 2016-12-19
ANNUAL REPORT 2016-04-01
ANNUAL REPORT 2015-03-18
ANNUAL REPORT 2014-02-19

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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