| Entity Name: | SPINE & SPORT INSTITUTE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 04 Nov 1996 (28 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 02 Sep 2022 (2 years ago) |
| Document Number: | P96000090411 |
| FEI/EIN Number | 65-0704415 |
| Address: | 515 n flagler dr., suite 402, west palm beach, FL 33401 |
| Mail Address: | 515 n flagler dr., suite 402, west palm beach, FL 33401 |
| ZIP code: | 33401 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1962530659 | 2007-03-02 | 2014-02-28 | 1345 36TH ST, VERO BEACH, FL, 329604848, US | 1345 36TH ST, VERO BEACH, FL, 329604848, US | |||||||||||||||||||||||||
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| Phone | +1 772-567-8040 |
| Fax | 7725678420 |
Authorized person
| Name | MS. MARJORIE R RODD |
| Role | CEO |
| Phone | 7725678040 |
Taxonomy
| Taxonomy Code | 225100000X - Physical Therapist |
| License Number | PT#007940 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS PROVIDER # |
| Number | Y5581 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| West, Dylan | Agent | 515 N. Flagler Drive, Ste. 402, West Palm Beach, FL 33401 |
| Name | Role | Address |
|---|---|---|
| RAPP, THOMAS | Chairman | 515 N. Flagler Drive, Ste. 402 West Palm Beach, FL 33401 |
| Name | Role | Address |
|---|---|---|
| RAPP, THOMAS | Chief Executive Officer | 515 N. Flagler Drive, Ste. 402 West Palm Beach, FL 33401 |
| Name | Role | Address |
|---|---|---|
| RAPP, THOMAS | Director | 515 N. Flagler Drive, Ste. 402 West Palm Beach, FL 33401 |
| Name | Role | Address |
|---|---|---|
| DIPIETRO, AMANDA | Officer | 515 n flagler dr., suite 402 west palm beach, FL 33401 |
| Name | Role | Address |
|---|---|---|
| Tucker, Jeffrey | Other | 515 n flagler dr., suite 402 west palm beach, FL 33401 |
| West, Dylan | Other | 515 N Flagler Drive, Suite 402 West Palm Beach, FL 33401 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000117600 | PREMIER PHYSICAL THERAPY AND SPORTS MEDICINE | ACTIVE | 2023-09-22 | 2028-12-31 | No data | PO BOX 8600, PORT ST. LUCIE, FL, 34985 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2024-02-13 | West, Dylan | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-02-28 | 515 N. Flagler Drive, Ste. 402, West Palm Beach, FL 33401 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2022-09-02 | 515 n flagler dr., suite 402, west palm beach, FL 33401 | No data |
| AMENDMENT | 2022-09-02 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2022-09-02 | 515 n flagler dr., suite 402, west palm beach, FL 33401 | No data |
| REINSTATEMENT | 2010-09-28 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2010-09-24 | No data | No data |
| AMENDMENT | 2001-04-17 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-13 |
| AMENDED ANNUAL REPORT | 2023-03-17 |
| ANNUAL REPORT | 2023-02-28 |
| Amendment | 2022-09-02 |
| ANNUAL REPORT | 2022-03-03 |
| ANNUAL REPORT | 2021-01-28 |
| ANNUAL REPORT | 2020-05-26 |
| ANNUAL REPORT | 2019-05-01 |
| ANNUAL REPORT | 2018-04-25 |
| ANNUAL REPORT | 2017-04-28 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 2117147200 | 2020-04-15 | 0455 | PPP | 1345 36th st Suite A, VERO BEACH, FL, 32960 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 1430718704 | 2021-03-27 | 0455 | PPS | 1355 37th St A, Vero Beach, FL, 32960-7321 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 02 Feb 2025
Sources: Florida Department of State
