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  5. CHAMPION UROLOGY, LTD

CHAMPION UROLOGY, LTD

Headquarter

Company Details

Name: CHAMPION UROLOGY, LTD
Jurisdiction: Rhode Island
Entity type: Domestic Profit Corporation
Status: Dissolved
Date of Organization in Rhode Island: 24 Dec 2001 (23 years ago)
Date of Dissolution: 13 Jan 2021 (4 years ago)
Date of Status Change: 13 Jan 2021 (4 years ago)
Identification Number: 000121932
ZIP code: 02891
County: Washington County
Principal Address: 35 WELLS STREET, WESTERLY, RI, 02891, USA
Purpose: MEDICAL PRACTICE
NAICS: 621111 - Offices of Physicians (except Mental Health Specialists)

Links between entities

Type Company Name Company Number State
Headquarter of CHAMPION UROLOGY, LTD, CONNECTICUT 1056994 CONNECTICUT

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1013925965 2006-08-04 2008-04-25 35 WELLS ST, WESTERLY, RI, 028912922, US 35 WELLS STREET, WESTERLY, RI, 02891, US

Contacts
Phone +1 401-596-0964
Fax 4015968634

Authorized person
Name MRS. CONSTANCE LIN LUTZEL
Role OFFICE MANAGER
Phone 4015960964

Taxonomy
Taxonomy Code 208800000X - Urology Physician
License Number 7511
State RI
Is Primary Yes
Taxonomy Code 208800000X - Urology Physician
License Number 10831
State RI
Is Primary No
Taxonomy Code 208800000X - Urology Physician
License Number 040289
State CT
Is Primary No

Other Provider Identifiers
Issuer MEDICAID
Number 003114204
State CT
Issuer MEDICAID
Number CU43922
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
CHAMPION UROLOGY, LTD 401(K) 2023 020537108 2024-05-30 CHAMPION UROLOGY, LTD 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 02891

Signature of
Role Plan administrator
Date 2024-05-30
Name of individual signing FRANKLIN LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY, LTD 401(K) 2023 020537108 2024-06-06 CHAMPION UROLOGY, LTD 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 02891

Signature of
Role Plan administrator
Date 2024-06-06
Name of individual signing FRANKLIN LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY, LTD 401(K) PLAN 2018 020537108 2019-08-21 CHAMPION UROLOGY, LTD 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 02891

Signature of
Role Plan administrator
Date 2019-08-21
Name of individual signing FRANKLIN LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY, LTD. 401(K) PLAN 2017 020537108 2018-04-25 CHAMPION UROLOGY, LTD. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922
CHAMPION UROLOGY, LTD. 401(K) PLAN 2016 020537108 2017-06-21 CHAMPION UROLOGY, LTD. 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922
CHAMPION UROLOGY, LTD. 401(K) PLAN 2015 020537108 2016-06-30 CHAMPION UROLOGY, LTD. 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922
CHAMPION UROLOGY LTD 401(K) PLAN 2014 020537108 2015-05-12 CHAMPION UROLOGY LTD 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Signature of
Role Plan administrator
Date 2015-05-12
Name of individual signing FRANKLIN F. LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY LTD 401(K) PLAN 2013 020537108 2014-05-28 CHAMPION UROLOGY LTD 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Signature of
Role Plan administrator
Date 2014-05-28
Name of individual signing FRANKLIN F. LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY LTD 401(K) PLAN 2012 020537108 2013-04-10 CHAMPION UROLOGY LTD 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Signature of
Role Plan administrator
Date 2013-04-10
Name of individual signing FRANKLIN F. LEDDY
Valid signature Filed with authorized/valid electronic signature
CHAMPION UROLOGY LTD 401(K) PROFIT SHARING PLAN &TRUST 2011 020537108 2012-06-28 CHAMPION UROLOGY LTD 11
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Plan administrator’s name and address
Administrator’s EIN 020537108
Plan administrator’s name CHAMPION UROLOGY LTD
Plan administrator’s address 35 WELLS ST, WESTERLY, RI, 028912922
Administrator’s telephone number 4015960964

Signature of
Role Plan administrator
Date 2012-06-28
Name of individual signing FRANKLIN F. LEDDY
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/04/20/20110420110931P030003895877001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Plan administrator’s name and address
Administrator’s EIN 020537108
Plan administrator’s name CHAMPION UROLOGY LTD
Plan administrator’s address 35 WELLS ST, WESTERLY, RI, 028912922
Administrator’s telephone number 4015960964

Signature of
Role Plan administrator
Date 2011-04-20
Name of individual signing FRANKLIN F. LEDDY, M.D.
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2010/06/30/20100630184111P030345068113001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2005-01-01
Business code 621111
Sponsor’s telephone number 4015960964
Plan sponsor’s address 35 WELLS ST, WESTERLY, RI, 028912922

Plan administrator’s name and address
Administrator’s EIN 020537108
Plan administrator’s name CHAMPION UROLOGY LTD
Plan administrator’s address 35 WELLS ST, WESTERLY, RI, 028912922
Administrator’s telephone number 4015960964

Signature of
Role Plan administrator
Date 2010-06-30
Name of individual signing FRANKLIN F. LEDDY, M.D.
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
WILLIAM A. NARDONE Agent 42 GRANITE STREET, WESTERLY, RI, 02891, USA

PRESIDENT

Name Role Address
FRANKLIN F LEDDY MD PRESIDENT 35 WELLS STREET WESTERLY, RI 02891- USA

Filings

Number Name File Date
202186019090 Articles of Dissolution 2021-01-13
202038668940 Annual Report 2020-04-24
202038669370 Annual Report 2020-04-24
202038668850 Reinstatement 2020-04-24
201924576930 Revocation Certificate For Failure to File the Annual Report for the Year 2019-10-18
201907034370 Revocation Notice For Failure to File An Annual Report 2019-07-24
201857912340 Annual Report 2018-02-08
201740851280 Annual Report 2017-04-13
201693526280 Annual Report 2016-02-29
201581341870 Annual Report 2015-10-02

Related by officers

WILLIAM A. NARDONE

DEETZ CONSTRUCTION, INC. SAND CASTLE MOTEL, INC. WEEKAPAUG YACHT CLUB SWEET-ALLEN FARM, INC. PECKHAM FARM, INC. CUSTOM CONCRETE FORMS, INC. S. CHIMENTO, INC. WOOD RIVER LANDING CORPORATION TRIANGLE ELECTRIC, INC. PELOQUIN BUILDERS INC.

Related by address

35 WELLS STREET, WESTERLY, RI, 02891, USA

ACTIVE ORTHOPEDIC ASSOCIATES, INC. CHAMPION PHYSICIANS, L.L.C. LEDDY UROLOGY PROPERTIES, LLC CHAMPION UROLOGY PROPERTIES, LLC ADVANCED SPINE AND PAIN MANAGEMENT, INC. CHAMPION MYSTIC PROPERTIES, LLC

Date of last update: 09 Oct 2024

Sources: Rhode Island Department of State

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