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Jasper Family Practice Center, P.C.

Details

Name: Jasper Family Practice Center, P.C.
Jurisdiction: Alabama
Legal type: Domestic Professional Corporation
Status: Exists
Date of registration: 02 Dec 1985 (39 years ago)
Entity Number: 000-108-033
Register Number: 000108033
County: Walker
Place of Formation: Walker County
Principal Address: JASPER, AL
Registered Office Street Address: 220 AIRPORT ROADJASPER, AL 35501
Registered Office Street Address ZIP Code: 35501
Authorized Capital: $1,000

Activities MEDICINE

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1275535361 2005-08-10 2022-07-21 PO BOX 1474, JASPER, AL, 355021474, US 2201 N AIRPORT RD, JASPER, AL, 355047058, US

Contacts
Phone +1 205-221-9351
Fax 2052213700
Fax 2052214353

Authorized person
Name DELINDA STILES
Role ASSISTANT OFFICE MANAGER
Phone 2052219351

Taxonomy
Taxonomy Code 207Q00000X - Family Medicine Physician
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 528601190
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
JASPER FAMILY PRACTICE CENTER, PC 401K PSP 2023 630919019 2024-07-18 JASPER FAMILY PRACTICE CENTER, P.C 43
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s address P.O. BOX 1474, JASPER, AL, 35502

Plan administrator’s name and address
Administrator’s EIN 630926271
Plan administrator’s name BENETECH ADMINISTRATORS, INC.
Plan administrator’s address P.O. BOX 530967, BIRMINGHAM, AL, 35253
Administrator’s telephone number 2058792824

Signature of
Role Plan administrator
Date 2024-07-18
Name of individual signing ALAN SPAIN
JASPER FAMILY PRACTICE CENTER, PC 401K PSP 2022 630919019 2023-12-27 JASPER FAMILY PRACTICE CENTER, P.C 39
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s address P.O. BOX 1474, JASPER, AL, 35502

Plan administrator’s name and address
Administrator’s EIN 630926271
Plan administrator’s name BENETECH ADMINISTRATORS, INC.
Plan administrator’s address P.O. BOX 530967, BIRMINGHAM, AL, 35253
Administrator’s telephone number 2058792824

Signature of
Role Plan administrator
Date 2023-12-27
Name of individual signing ALAN SPAIN
JASPER FAMILY PRACTICE CENTER, PC 401K PSP 2022 630919019 2023-10-13 JASPER FAMILY PRACTICE CENTER, P.C 42
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s address P.O. BOX 1474, JASPER, AL, 35502

Plan administrator’s name and address
Administrator’s EIN 630926271
Plan administrator’s name BENETECH ADMINISTRATORS, INC.
Plan administrator’s address P.O. BOX 530967, BIRMINGHAM, AL, 35253
Administrator’s telephone number 2058792824

Signature of
Role Plan administrator
Date 2023-10-13
Name of individual signing ALAN SPAIN
JASPER FAMILY PRACTICE CENTER, PC 401K PSP 2021 630919019 2023-12-14 JASPER FAMILY PRACTICE CENTER, P.C 37
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s address P.O. BOX 1474, JASPER, AL, 35502
JASPER FAMILY PRACTICE CENTER, PC PROFIT SHARING 401(K) PLAN 2009 630919019 2010-10-18 JASPER FAMILY PRACTICE CENTER, P.C. 33
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s mailing address 2201 NORTH AIRPORT ROAD, JASPER, AL, 35504
Plan sponsor’s address PO BOX 1474, JASPER, AL, 35502

Plan administrator’s name and address
Administrator’s EIN 630919019
Plan administrator’s name JASPER FAMILY PRACTICE CENTER, P.C.
Plan administrator’s address 2201 NORTH AIRPORT ROAD, JASPER, AL, 35504
Administrator’s telephone number 2052219351

Number of participants as of the end of the plan year
Active participants 28
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 19
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 47
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2010-10-18
Name of individual signing DR. DERRICK BOWLING
Valid signature Filed with authorized/valid electronic signature
JASPER FAMILY PRACTICE CENTER, PC PROFIT SHARING 401(K) PLAN 2009 630919019 2010-10-15 JASPER FAMILY PRACTICE CENTER, P.C. 33
Three-digit plan number (PN) 001
Effective date of plan 1986-05-01
Business code 621111
Sponsor’s telephone number 2052219351
Plan sponsor’s mailing address 2201 NORTH AIRPORT ROAD, JASPER, AL, 35504
Plan sponsor’s address PO BOX 1474, JASPER, AL, 35502

Plan administrator’s name and address
Administrator’s EIN 630919019
Plan administrator’s name JASPER FAMILY PRACTICE CENTER, P.C.
Plan administrator’s address 2201 NORTH AIRPORT ROAD, JASPER, AL, 35504
Administrator’s telephone number 2052219351

Number of participants as of the end of the plan year
Active participants 28
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 19
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 47
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 0

Signature of
Role Plan administrator
Date 2010-10-15
Name of individual signing DR. DERRICK BOWLING
Valid signature Filed with incorrect/unrecognized electronic signature

Agent

Name Role
GARDNER, ANN Agent

Incorporator

Name Role
CAMP, N T MD Incorporator

Events

Event Date Event Type Old Value New Value
2001-01-16 Name Merged No data N. T. Camp, M.D., P.C.
1991-04-17 Capital Change $100 Authorized --- Paid In $1,000 Authorized undefined Paid In

Related by officers

GARDNER, ANN

SouthGate Technologies, Inc. I.T. National Sales, Inc. Just For You Senior Daycare, Inc. HMC Rural Health Clinic, LLC

CAMP, N T MD

N. T. Camp, M.D., P.C. Jasper Family Counseling Services, P.C. HCM Properties, Inc. Jasper Family Clinic, P.A.

Related by address

JASPER, AL

Viking Office Supply, Inc. Allied Steel Products Corporation American Glass Company, Inc. B G's Inc. Uptown Motors, Inc. Gardner Homes, Inc. Bankhead-Gardner, Inc. John H. Bankhead & Company, Inc. Barton Drug of Jasper, Inc. Bishop Coal Company, Inc.

Date of last update: 31 Jul 2024

Sources: Alabama Secretary of State

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