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TRI-STATE FAMILY MEDICINE, PSC

Company Details

Name: TRI-STATE FAMILY MEDICINE, PSC
Jurisdiction: Kentucky
Profit or Non-Profit: Profit
Legal type: Kentucky Professional Services Corp
Status: Inactive
Standing: Bad
File Date: 12 Apr 2006 (19 years ago)
Organization Date: 12 Apr 2006 (19 years ago)
Last Annual Report: 18 Mar 2016 (9 years ago)
Organization Number: 0636582
Industry: Health Services
Number of Employees: Small (0-19)
Principal Office: 73 PRIVATE DRIVE 633, CHESAPEAKE, OH 45619
Place of Formation: KENTUCKY
Authorized Shares: 100

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2016 204691731 2017-10-16 TRI STATE FAMILY MEDICINE, PSC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2015 204691731 2016-10-17 TRI STATE FAMILY MEDICINE, PSC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2014 204691731 2015-10-06 TRI STATE FAMILY MEDICINE, PSC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2015-10-06
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2013 204691731 2014-07-30 TRI STATE FAMILY MEDICINE, PSC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2014-07-30
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2012 204691731 2013-07-29 TRI STATE FAMILY MEDICINE, PSC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2013-07-29
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2011 204691731 2012-10-08 TRI STATE FAMILY MEDICINE, PSC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2012-10-08
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2010 204691731 2012-10-08 TRI STATE FAMILY MEDICINE, PSC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2012-10-08
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2010 204691731 2011-10-18 TRI STATE FAMILY MEDICINE, PSC 4
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2011-10-18
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
TRI STATE FAMILY MEDICINE PSC 401(K) PROFIT SHARING PLAN 2009 204691731 2010-10-14 TRI STATE FAMILY MEDICINE, PSC 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2007-01-01
Business code 621111
Sponsor’s telephone number 6063250042
Plan sponsor’s address 941 29TH STREET, ASHLAND, KY, 41101

Plan administrator’s name and address
Administrator’s EIN 204691731
Plan administrator’s name TRI STATE FAMILY MEDICINE, PSC
Plan administrator’s address 941 29TH STREET, ASHLAND, KY, 41101
Administrator’s telephone number 6063250042

Signature of
Role Plan administrator
Date 2010-10-13
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-10-13
Name of individual signing ARASH KAYFAN, M.D.
Valid signature Filed with authorized/valid electronic signature

Registered Agent

Name Role
MICHAEL D. ROBINSON Registered Agent

CEO

Name Role
arash daemi kayfan CEO

Shareholder

Name Role
arash daemi kayfan Shareholder

Incorporator

Name Role
ARASH KAYFAN, DO Incorporator

Assumed Names

Name Status Expiration Date
WAIST CONTROL WEIGHT LOSS Inactive 2016-08-05

Filings

Name File Date
Reinstatement Approval Letter Revenue 2024-11-07
Administrative Dissolution 2017-10-09
Annual Report 2016-03-18
Annual Report 2015-04-24
Annual Report 2014-06-24
Annual Report 2013-06-06
Annual Report 2012-06-20
Certificate of Assumed Name 2011-08-05
Annual Report 2011-05-13
Annual Report 2010-05-18

Related by officers

MICHAEL D. ROBINSON

R & H ENTERPRISES, INC. KELLEY GALLOWAY SMITH GOOLSBY, PSC ROBCO, INC. KIMBERLY M. BALDOCK, MD, PSC V & R CONSTRUCTION, LLC HOLISTIC VENTURES LLC KATRINA B. BRIGGS, M.D., PSC PK1923, PSC RALPH HESS, DO, PSC. JOHN S. HAID, MD, PSC

Related by address

No related companies by address

Date of last update: 11 Jan 2025

Sources: Kentucky Secretary of State

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