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  5. Hospice of Montgomery, Inc.

Hospice of Montgomery, Inc.

Details

Name: Hospice of Montgomery, Inc.
Jurisdiction: Alabama
Legal type: Domestic Non-Profit Corporation
Status: Exists
Date of registration: 18 Apr 1979 (46 years ago)
Entity Number: 000-368-854
Register Number: 000368854
ZIP code: 36117
County: Montgomery
Place of Formation: Montgomery County
Principal Address: 1111 HOLLOWAY PARKMONTGOMERY, AL 36117

Activities EXCLUSIVELY FOR RELIGIOUS
CHARITABLE
LITERARY AND EDUCATIONAL PURPOSES

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1144273160 2006-05-19 2020-08-22 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902, US 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902, US

Contacts
Phone +1 334-279-6677
Fax 3342772223

Authorized person
Name MS. JENILLE V BALL
Role EXECUTIVE DIRECTOR
Phone 3342796677

Taxonomy
Taxonomy Code 251G00000X - Community Based Hospice Care Agency
License Number 11724
State AL
Is Primary Yes

Other Provider Identifiers
Issuer BLUE CROSS BLUE SHIELD
Number 010371
State AL
Issuer MEDICAID
Number PIC1523E
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
403 (B) THRIFT PLAN - HOSPICE OF MONTGOMERY, INC 2022 630768381 2024-03-28 HOSPICE OF MONTGOMERY, INC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Plan sponsor’s mailing address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117

Number of participants as of the end of the plan year
Active participants 0
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 9
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 9
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 2024-03-28
Name of individual signing MELISSA WOODRUFF
Valid signature Filed with authorized/valid electronic signature
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2021 630768381 2022-04-25 HOSPICE OF MONTGOMERY, INC. 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 622000
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902

Signature of
Role Plan administrator
Date 2022-04-25
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2020 630768381 2022-04-25 HOSPICE OF MONTGOMERY, INC. 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 622000
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902

Signature of
Role Plan administrator
Date 2022-04-25
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2020 630768381 2021-03-18 HOSPICE OF MONTGOMERY, INC. 16
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 622000
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902

Signature of
Role Plan administrator
Date 2021-03-18
Name of individual signing MELISSA WOODRUFF
403 (B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC 2018 630768381 2020-03-25 HOSPICE OF MONTGOMERY, INC 16
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 622000
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117

Signature of
Role Plan administrator
Date 2020-03-25
Name of individual signing MELISSA WOODRUFF
Role Employer/plan sponsor
Date 2020-03-25
Name of individual signing MELISSA WOODRUFF
403 (B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC 2017 630768381 2019-02-26 HOSPICE OF MONTGOMERY, INC 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902

Signature of
Role Plan administrator
Date 2019-02-26
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2016 630768381 2018-04-27 HOSPICE OF MONTGOMERY, INC. 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117

Signature of
Role Plan administrator
Date 2018-04-27
Name of individual signing MELISSA WOODRUFF
Role Employer/plan sponsor
Date 2018-04-27
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2015 630768381 2017-04-26 HOSPICE OF MONTGOMERY, INC. 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117

Signature of
Role Plan administrator
Date 2017-04-26
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY INC 2015 630768381 2017-04-25 HOSPICE OF MONTGOMERY INC 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902

Plan administrator’s name and address
Administrator’s EIN 630768381
Plan administrator’s name MELISSA WOODRUFF
Plan administrator’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 361171902
Administrator’s telephone number 3342796677

Signature of
Role Plan administrator
Date 2017-04-25
Name of individual signing MELISSA WOODRUFF
403(B) THRIFT PLAN OF HOSPICE OF MONTGOMERY, INC. 2014 630768381 2016-04-04 HOSPICE OF MONTGOMERY, INC. 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1996-01-01
Business code 621610
Sponsor’s telephone number 3342796677
Plan sponsor’s address 1111 HOLLOWAY PARK, MONTGOMERY, AL, 36117

Signature of
Role Plan administrator
Date 2016-04-04
Name of individual signing MELISSA WOODRUFF

Agent

Name Role
WOODRUFF, MELISSA Agent

Director

Name Role Address
FORREST NEELY Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
FRANK HAWTHORNE Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
LEE SIMS Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
DR. ARTHUR MAZYCK Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
JASON BRYANT Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
JOE B RILEY, RN, FACHE Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
DR GLEN YATES Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
DR. KATHY WINDHAM Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
DR WILLIAM SALISKE Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117
DR. LEENA BHASIN Director 111 HOLLOWAY PARKMONTGOMERY, AL 36117

Incorporator

Name Role Address
SPARKS, T C Incorporator ROUTE 2 BOX 624MILLBROOK, AL 36054
ABRAHAM, JOHN Incorporator No data
BLOCH, KENNETH Incorporator No data
POTEET, JAMES Incorporator 3980 GOVERNORS DRIVEMONTGOMERY, AL 36111
GILL, JOEL Incorporator ROUTE 4-7012 TIFTON AVEMONTGOMERY, AL 36116
HAWKINS, GEORGE Incorporator 450 BOWLING GREEN DRIVEMONTGOMERY, AL 36109
RUFFIN, WANDA Incorporator 3821 PINEY CURVEMONTGOMERY, AL 36111
HASLAM, DOCIA L Incorporator 428 SOUTH LAWRENCE STREETMONGOMERY, AL 36104
CARMICHAEL, MALCOLM N Incorporator PO BOX 429MONTGOMERY, AL 36101
GORDON, EVE Incorporator 5713 WORCHESTER DRIVEMONTGOMERY, AL 36116

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Related by address

No related companies by address

Date of last update: 13 Aug 2024

Sources: Alabama Secretary of State

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