SOUTH FORK MEDICAL CLINIC PLLC

Business Information

Congressional District	05
State/Country of Incorporation	KY, USA
Activation Date	2024-02-07
Initial Registration Date	2010-01-13
Entity Start Date	2002-12-16
Fiscal Year End Close Date	Dec 31

Service Classifications

NAICS Codes

621111

Points of Contacts

Electronic Business
Title	PRIMARY POC
Name	JENNY ANN CORRELL
Role	BILLIN SUPERVISOR
Address	PO BOX 250, WHITLEY CITY, KY, 42653, USA
Title	ALTERNATE POC
Name	MONICA S LAWSON
Role	MANAGING MEMBER
Address	PO BOX 250, WHITLEY CITY, KY, 42653, USA

Government Business
Title	PRIMARY POC
Name	WILLIAM SINGLETON
Role	CFO
Address	PO BOX 250, WHITLEY CITY, KY, 42653, USA
Title	ALTERNATE POC
Name	MONICA S LAWSON
Role	MANAGING MEMBER
Address	PO BOX 250, WHITLEY CITY, KY, 42653, USA

Past Performance	Information not Available

File	View Page
Three-digit plan number (PN)	501
Effective date of plan	2022-01-01
Business code	621491
Sponsor’s telephone number	6063109726
Plan sponsor’s address	71 MEDICAL LANE, WHITLEY CITY, KY, 42653

Plan administrator’s name and address

Administrator’s EIN	846429706
Plan administrator’s name	SHAWNA BURTON
Plan administrator’s address	464 CHENAULT RD, FRANKFORT, KY, 40601
Administrator’s telephone number	5026954700

Signature of

Role	Plan administrator
Date	2023-12-27
Name of individual signing	SHAWNA BURTON
Valid signature	Filed with authorized/valid electronic signature

Three-digit plan number (PN)	501
Effective date of plan	2022-01-01
Business code	621491
Sponsor’s telephone number	6063109726
Plan sponsor’s address	71 MEDICAL LANE, WHITLEY CITY, KY, 42653

Plan administrator’s name and address

Administrator’s EIN	846429706
Plan administrator’s name	SHAWNA BURTON
Plan administrator’s address	464 CHENAULT RD, FRANKFORT, KY, 40601
Administrator’s telephone number	5026954700

Signature of

Role	Plan administrator
Date	2022-12-29
Name of individual signing	SHAWNA BURTON
Valid signature	Filed with authorized/valid electronic signature