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  5. FLORIDA SPORTS MEDICINE INSTITUTE, INC.

FLORIDA SPORTS MEDICINE INSTITUTE, INC.

Company Details

Entity Name: FLORIDA SPORTS MEDICINE INSTITUTE, INC.
Jurisdiction: FLORIDA
Filing Type: Florida Profit Corporation
Status: Inactive
Date Filed: 24 Sep 1997 (27 years ago)
Date of dissolution: 28 Sep 2018 (6 years ago)
Last Event: ADMIN DISSOLUTION FOR ANNUAL REPORT
Event Date Filed: 28 Sep 2018 (6 years ago)
Document Number: P97000082801
FEI/EIN Number 59-3463989
Address: 150 SOUTHPARK BLVD., SUITE 102, SAINT AUGUSTINE, FL 32086
Mail Address: 150 SOUTHPARK BLVD., SUITE 102, SAINT AUGUSTINE, FL 32086
ZIP code: 32086
County: St. Johns
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1467621003 2008-02-28 2010-01-06 150 SOUTHPARK BLVD, SUITE 102, ST AUGUSTINE, FL, 320865190, US 4131 UNIVERSITY BLVD S, SUITE 15, JACKSONVILLE, FL, 322164326, US

Contacts
Phone +1 904-823-3764
Fax 9044290318
Phone +1 904-854-4587

Authorized person
Name MS. KAREN LYNN HASELTINE
Role CEO
Phone 9048233764

Taxonomy
Taxonomy Code 207XX0005X - Sports Medicine (Orthopaedic Surgery) Physician
License Number OS7217
State FL
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2015 593463989 2016-04-29 FLORIDA SPORTS MEDICINE INSTITUTE 19
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Signature of
Role Plan administrator
Date 2016-04-29
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2014 593463989 2015-10-12 FLORIDA SPORTS MEDICINE INSTITUTE 23
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Signature of
Role Plan administrator
Date 2015-10-12
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2013 593463989 2014-05-19 FLORIDA SPORTS MEDICINE INSTITUTE 21
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Signature of
Role Plan administrator
Date 2014-05-19
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2012 593463989 2013-07-16 FLORIDA SPORTS MEDICINE INSTITUTE 24
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Signature of
Role Plan administrator
Date 2013-07-16
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2011 593463989 2012-09-18 FLORIDA SPORTS MEDICINE INSTITUTE 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Plan administrator’s name and address
Administrator’s EIN 593463989
Plan administrator’s name FLORIDA SPORTS MEDICINE INSTITUTE
Plan administrator’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086
Administrator’s telephone number 9048233764

Signature of
Role Plan administrator
Date 2012-09-18
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2012-09-18
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2010 593463989 2011-06-23 FLORIDA SPORTS MEDICINE INSTITUTE 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Plan administrator’s name and address
Administrator’s EIN 593463989
Plan administrator’s name FLORIDA SPORTS MEDICINE INSTITUTE
Plan administrator’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086
Administrator’s telephone number 9048233764

Signature of
Role Plan administrator
Date 2011-06-23
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2010 593463989 2011-06-23 FLORIDA SPORTS MEDICINE INSTITUTE 28
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Plan administrator’s name and address
Administrator’s EIN 593463989
Plan administrator’s name FLORIDA SPORTS MEDICINE INSTITUTE
Plan administrator’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086
Administrator’s telephone number 9048233764

Signature of
Role Plan administrator
Date 2011-06-23
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature
FLORIDA SPORTS MEDICINE INSTITUTE 401(K) SALARY DEFERRAL PLAN 2009 593463989 2010-07-20 FLORIDA SPORTS MEDICINE INSTITUTE 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1999-01-01
Business code 621340
Sponsor’s telephone number 9048233764
Plan sponsor’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086

Plan administrator’s name and address
Administrator’s EIN 593463989
Plan administrator’s name FLORIDA SPORTS MEDICINE INSTITUTE
Plan administrator’s address 150 SOUTHPARK BLVD., SUITE 102, ST. AUGUSTINE, FL, 32086
Administrator’s telephone number 9048233764

Signature of
Role Plan administrator
Date 2010-07-20
Name of individual signing KAREN L. HASELTINE
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role
HALL & EDWARDS, PA Agent

Chief Executive Officer

Name Role Address
HASELTINE, KAREN L Chief Executive Officer 150 SOUTHPARK BLVD., STE 102, SAINT AUGUSTINE, FL 32086

Events

Event Type Filed Date Value Description
ADMIN DISSOLUTION FOR ANNUAL REPORT 2018-09-28 No data No data
REGISTERED AGENT ADDRESS CHANGED 2014-04-29 3791 A1A SOUTH, SUITE B, ST. AUGUSTINE, FL 32080 No data
REGISTERED AGENT NAME CHANGED 2014-04-29 HALL & EDWARDS, PA No data
CHANGE OF PRINCIPAL ADDRESS 2003-04-14 150 SOUTHPARK BLVD., SUITE 102, SAINT AUGUSTINE, FL 32086 No data
CHANGE OF MAILING ADDRESS 2003-04-14 150 SOUTHPARK BLVD., SUITE 102, SAINT AUGUSTINE, FL 32086 No data
REINSTATEMENT 1999-10-14 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 1999-09-24 No data No data
AMENDMENT AND NAME CHANGE 1997-12-15 FLORIDA SPORTS MEDICINE INSTITUTE, INC. No data

Debts

Document Number Status Case Number Name of Court Date of Entry Expiration Date Amount Due Plaintiff
J19000174563 TERMINATED 1000000817771 DUVAL 2019-03-04 2029-03-06 $ 514.54 STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825
J18000198556 ACTIVE 1000000781865 ST JOHNS 2018-05-17 2028-05-23 $ 757.28 STATE OF FLORIDA, DEPARTMENT OF REVENUE, JACKSONVILLE SERVICE CENTER, 921 N DAVIS ST STE 250A, JACKSONVILLE FL322096825
J12000137474 TERMINATED 1000000252191 ST JOHNS 2012-02-21 2032-03-01 $ 21,961.62 STATE OF FLORIDA, DEPARTMENT OF REVENUE, OUT OF STATE/CENTRAL COLLECTIONS UNIT, 5050 W TENNESSEE ST, TALLAHASSEE FL323996586

Documents

Name Date
ANNUAL REPORT 2017-05-15
ANNUAL REPORT 2016-04-26
ANNUAL REPORT 2015-04-24
ANNUAL REPORT 2014-04-29
ANNUAL REPORT 2013-04-12
ANNUAL REPORT 2012-04-27
ANNUAL REPORT 2011-04-22
ANNUAL REPORT 2010-04-23
ANNUAL REPORT 2009-04-29
ANNUAL REPORT 2008-04-25

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 01 Feb 2025

Sources: Florida Department of State

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