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  5. FIRST COAST LTC, INC.

FIRST COAST LTC, INC.

Company Details

Entity Name: FIRST COAST LTC, INC.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Active
Date Filed: 25 Mar 1999 (26 years ago)
Document Number: P99000029184
FEI/EIN Number 593567314
Address: 6555 Chester Ave, Suite 1, Jacksonville, FL, 32217, US
Mail Address: 6555 Chester Ave, Suite 1, Jacksonville, FL, 32217, US
ZIP code: 32217
County: Duval
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1538418868 2012-08-31 2016-03-07 6555 CHESTER AVE STE 1, JACKSONVILLE, FL, 322172279, US 25 STATE ROAD 13, ATT: CLINIC, SAINT JOHNS, FL, 322592842, US

Contacts
Phone +1 904-309-6504
Fax 9045033577

Authorized person
Name DR. DAVID SAMARA
Role PRESIDENT
Phone 9043096504

Taxonomy
Taxonomy Code 208D00000X - General Practice Physician
License Number ME31637
State FL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 371340700
State FL
Issuer RR MEDICARE
Number CG-1814

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
FIRST COAST LTC, INC. 401(K) PROFIT SHARING PLAN 2020 593567314 2021-02-01 FIRST COAST LTC, INC. 19
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621111
Sponsor’s telephone number 9042658209
Plan sponsor’s DBA name 1/1/2016
Plan sponsor’s address 6555 CHESTER AVENUE, SUITE 1, JACKSONVILLE, FL, 322172279

Signature of
Role Plan administrator
Date 2021-02-01
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-02-01
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
FIRST COAST LTC, INC. 401(K) PROFIT SHARING PLAN 2019 593567314 2020-08-12 FIRST COAST LTC, INC. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621111
Sponsor’s telephone number 9042658209
Plan sponsor’s address 6555 CHESTER AVENUE, SUITE 1, JACKSONVILLE, FL, 322172279

Signature of
Role Plan administrator
Date 2020-08-12
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-08-12
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
FIRST COAST LTC, INC. 401(K) PROFIT SHARING PLAN 2018 593567314 2019-05-31 FIRST COAST LTC, INC. 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621111
Sponsor’s telephone number 9042658209
Plan sponsor’s address 6555 CHESTER AVENUE, SUITE 1, JACKSONVILLE, FL, 322172279

Signature of
Role Plan administrator
Date 2019-05-31
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-05-31
Name of individual signing DAVID SAMARA
Valid signature Filed with authorized/valid electronic signature
FIRST COAST LTC, INC. 401(K) PROFIT SHARING PLAN 2017 593567314 2018-07-31 FIRST COAST LTC, INC. 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621111
Sponsor’s telephone number 9042658209
Plan sponsor’s address 6555 CHESTER AVENUE, SUITE 1, JACKSONVILLE, FL, 322172279

Signature of
Role Plan administrator
Date 2018-07-31
Name of individual signing DAVID J. SAMARA
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-07-31
Name of individual signing DAVID J. SAMARA
Valid signature Filed with authorized/valid electronic signature
FIRST COAST LTC, INC. 401(K) PROFIT SHARING PLAN 2016 593567314 2017-09-22 FIRST COAST LTC, INC. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2016-01-01
Business code 621111
Sponsor’s telephone number 9042658209
Plan sponsor’s address 6555 CHESTER AVENUE, SUITE 1, JACKSONVILLE, FL, 322172279

Signature of
Role Plan administrator
Date 2017-09-22
Name of individual signing DAVID J. SAMARA, M.D.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-09-22
Name of individual signing DAVID J. SAMARA, M.D.
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Samara David Agent 6555 Chester Ave, Jacksonville, FL, 32217

Director

Name Role Address
SAMARA DAVID J Director 6555 Chester Ave, Jacksonville, FL, 32217

Events

Event Type Filed Date Value Description
REGISTERED AGENT NAME CHANGED 2022-01-26 Samara, David No data
REGISTERED AGENT ADDRESS CHANGED 2022-01-26 6555 Chester Ave, Suite 1, Jacksonville, FL 32217 No data
CHANGE OF PRINCIPAL ADDRESS 2017-01-08 6555 Chester Ave, Suite 1, Jacksonville, FL 32217 No data
CHANGE OF MAILING ADDRESS 2017-01-08 6555 Chester Ave, Suite 1, Jacksonville, FL 32217 No data

Documents

Name Date
ANNUAL REPORT 2025-01-05
ANNUAL REPORT 2024-01-09
ANNUAL REPORT 2023-01-10
ANNUAL REPORT 2022-01-26
ANNUAL REPORT 2021-01-16
ANNUAL REPORT 2020-02-11
ANNUAL REPORT 2019-02-17
ANNUAL REPORT 2018-01-30
ANNUAL REPORT 2017-01-08
ANNUAL REPORT 2016-02-06

Related by officers

SAMARA DAVID J

DASS HOLDINGS, LLC DSMD, LLC

Samara David

DSMD, LLC

Related by address

No related companies by address

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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