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  5. CHURCHVILLE-CHILI FAMILY MEDICINE, LLC

CHURCHVILLE-CHILI FAMILY MEDICINE, LLC

Company Details

Name: CHURCHVILLE-CHILI FAMILY MEDICINE, LLC
Jurisdiction: New York
Legal type: DOMESTIC PROFESSIONAL SERVICE LIMITED LIABILITY COMPANY
Status: Active
Date of registration: 12 Oct 2007 (17 years ago)
Entity Number: 3579295
ZIP code: 14514
County: Monroe
Place of Formation: New York
Address: 4201 BUFFALO RD, PO BOX 505, NORTH CHILI, NY, United States, 14514

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2023 464927775 2024-10-10 CHURCHVILLE-CHILI FAMILY MEDICINE 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, PO BOX 505, ORTH CHILI, NY, 145140505

Signature of
Role Plan administrator
Date 2024-10-10
Name of individual signing ADELE VAN DER VYVER
Valid signature Filed with authorized/valid electronic signature
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2022 464927775 2023-10-16 CHURCHVILLE-CHILI FAMILY MEDICINE 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, PO BOX 505, NORTH CHILI, NY, 145140505

Signature of
Role Plan administrator
Date 2023-10-16
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2021 464927775 2022-07-11 CHURCHVILLE-CHILI FAMILY MEDICINE 23
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, P.O. BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2022-07-11
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2020 464927775 2021-07-27 CHURCHVILLE-CHILI FAMILY MEDICINE 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address P.O. BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2021-07-27
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2019 464927775 2021-07-26 CHURCHVILLE-CHILI FAMILY MEDICINE 19
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address PO BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2021-07-26
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2019 161576149 2020-07-17 CHURCHVILLE-CHILI FAMILY MEDICINE 19
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address PO BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2020-07-17
Name of individual signing ADELE VAN DER VYVER
Role Employer/plan sponsor
Date 2020-07-17
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2018 161576149 2019-07-24 CHURCHVILLE-CHILI FAMILY MEDICINE LLC 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, P.O. BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2019-07-24
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2018 464927775 2019-07-25 CHURCHVILLE-CHILI FAMILY MEDICINE LLC 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, P.O. BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2019-07-25
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE-CHILI FAMILY MEDICINE 401(K) PLAN 2017 464927775 2018-07-12 CHURCHVILLE-CHILI FAMILY MEDICINE LLC 13
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address 4201 BUFFALO ROAD, P.O. BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2018-07-12
Name of individual signing ADELE VAN DER VYVER
CHURCHVILLE CHILI FAM. MED. PLAN 2016 464927775 2017-06-16 CHURCHVILLE CHILI FAMILY MEDICINE 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-09-01
Business code 621111
Sponsor’s telephone number 5855945995
Plan sponsor’s address PO BOX 505, NORTH CHILI, NY, 14514

Signature of
Role Plan administrator
Date 2017-06-16
Name of individual signing ADELE VAN DER VYVER

Agent

Name Role Address
HENRY PASZKO, M.D. Agent 4201 BUFFALO ROAD, NORTH CHILI, NY, 14514

DOS Process Agent

Name Role Address
(DELETE THE HYPHEN) CHURCHVILLE CHILI FAMILY MEDICINE, LLC DOS Process Agent 4201 BUFFALO RD, PO BOX 505, NORTH CHILI, NY, United States, 14514

History

Start date End date Type Value
2013-10-17 2023-10-02 Address 4201 BUFFALO RD, PO BOX 505, NORTH CHILI, NY, 14514, USA (Type of address: Service of Process)
2009-10-21 2013-10-17 Address 4201 BUFFALO RD, PO BOX 505, NORTH CHILI, NY, 14514, USA (Type of address: Service of Process)
2007-10-12 2023-10-02 Address 4201 BUFFALO ROAD, NORTH CHILI, NY, 14514, USA (Type of address: Registered Agent)
2007-10-12 2009-10-21 Address 4201 BUFFALO ROAD, NORTH CHILI, NY, 14514, USA (Type of address: Service of Process)

Filings

Filing Number Date Filed Type Effective Date
231002000609 2023-10-02 BIENNIAL STATEMENT 2023-10-01
211020001082 2021-10-20 BIENNIAL STATEMENT 2021-10-20
191003060243 2019-10-03 BIENNIAL STATEMENT 2019-10-01
171010006047 2017-10-10 BIENNIAL STATEMENT 2017-10-01
151016006215 2015-10-16 BIENNIAL STATEMENT 2015-10-01
131017006685 2013-10-17 BIENNIAL STATEMENT 2013-10-01
111031002350 2011-10-31 BIENNIAL STATEMENT 2011-10-01
091021002662 2009-10-21 BIENNIAL STATEMENT 2009-10-01
080102000574 2008-01-02 CERTIFICATE OF PUBLICATION 2008-01-02
071012000273 2007-10-12 ARTICLES OF ORGANIZATION 2007-10-12

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 27 Nov 2024

Sources: New York Secretary of State

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