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  5. FAIRLAWN PRIMARY CARE, INC.

FAIRLAWN PRIMARY CARE, INC.

Company Details

Name: FAIRLAWN PRIMARY CARE, INC.
Jurisdiction: Rhode Island
Entity type: Domestic Profit Corporation
Status: Activ
Date of Organization in Rhode Island: 12 Mar 2004 (21 years ago)
Identification Number: 000138661
ZIP code: 02860
County: Providence County
Principal Address: 966 MINERAL SPRING AVENUE, PAWTUCKET, RI, 02860, USA
Purpose: PROVIDING MEDICAL SERVICES
NAICS: 621111 - Offices of Physicians (except Mental Health Specialists)

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1508898909 2006-07-07 2020-08-22 886 MINERAL SPRING AVE, PAWTUCKET, RI, 028603322, US 886 MINERAL SPRING AVE, PAWTUCKET, RI, 028603322, US

Contacts
Phone +1 401-475-3063

Authorized person
Name MS. HOLLY FERNANDES
Role PRESIDENT
Phone 4014753063

Taxonomy
Taxonomy Code 207R00000X - Internal Medicine Physician
License Number 09843
State RI
Is Primary No
Taxonomy Code 363LF0000X - Family Nurse Practitioner
License Number NPP37132
State RI
Is Primary No

Other Provider Identifiers
Issuer MEDICAID
Number 9003461
State RI
Issuer MEDICAID
Number 7006714
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
FAIRLAWN PRIMARY CARE INC 401(K) PROFIT SHARING PLAN & TRUST 2023 200861787 2024-07-21 FAIRLAWN PRIMARY CARE INC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVENUE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2024-07-21
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401(K) PROFIT SHARING PLAN & TRUST 2022 200861787 2023-05-20 FAIRLAWN PRIMARY CARE INC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2023-05-20
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401(K) PROFIT SHARING PLAN & TRUST 2021 200861787 2022-07-04 FAIRLAWN PRIMARY CARE INC 6
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVENNUE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2022-07-04
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401(K) PROFIT SHARING PLAN & TRUST 2020 200861787 2021-07-21 FAIRLAWN PRIMARY CARE INC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2021-07-21
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401(K) PROFIT SHARING PLAN & TRUST 2019 200861787 2020-06-27 FAIRLAWN PRIMARY CARE INC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2020-06-27
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401 K PROFIT SHARING PLAN TRUST 2018 200861787 2019-06-21 FAIRLAWN PRIMARY CARE INC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2019-06-21
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401 K PROFIT SHARING PLAN TRUST 2017 200861787 2018-09-09 FAIRLAWN PRIMARY CARE INC 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVENUE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2018-09-09
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401 K PROFIT SHARING PLAN TRUST 2016 200861787 2017-07-28 FAIRLAWN PRIMARY CARE INC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2017-07-28
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401 K PROFIT SHARING PLAN TRUST 2015 200861787 2016-07-21 FAIRLAWN PRIMARY CARE INC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVENUE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2016-07-21
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
FAIRLAWN PRIMARY CARE INC 401 K PROFIT SHARING PLAN TRUST 2014 200861787 2015-07-30 FAIRLAWN PRIMARY CARE INC 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVENUE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2015-07-30
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2014/05/22/20140522120905P040053844087001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 866 MINERAL SPRING AVE, PAWTUCKET, RI, 02860

Signature of
Role Plan administrator
Date 2014-05-22
Name of individual signing FADI MANSOURATI
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/07/24/20130724150238P040116949013001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 966 MINERAL SPRING AVE, NORTH PROVIDENCE, RI, 02904

Signature of
Role Plan administrator
Date 2013-07-24
Name of individual signing FAIRLAWN PRIMARY CARE INC
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/07/26/20120726114813P030001298596001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2011-01-01
Business code 621112
Sponsor’s telephone number 4014753063
Plan sponsor’s address 866 MINERAL SPRING AVE, PAWTUCKET, RI, 02860

Plan administrator’s name and address
Administrator’s EIN 200861787
Plan administrator’s name FAIRLAWN PRIMARY CARE INC
Plan administrator’s address 866 MINERAL SPRING AVE, PAWTUCKET, RI, 02860
Administrator’s telephone number 4014753063

Signature of
Role Plan administrator
Date 2012-07-26
Name of individual signing FAIRLAWN PRIMARY CARE INC
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
JAMES A. BRIDEN, ESQ. Agent 17 HOLLOW RIDGE ROAD, RUMFORD, RI, 02916, USA

PRESIDENT

Name Role Address
FADI MANSOURATI MD PRESIDENT 966 MINERAL SPRING AVENUE PAWTUCKET, RI 02860 USA

Filings

Number Name File Date
202446765770 Annual Report 2024-02-16
202339761340 Statement of Change of Registered/Resident Agent Office 2023-07-25
202329882570 Annual Report 2023-03-01
202216834620 Annual Report 2022-04-28
202198416920 Annual Report 2021-06-17
202196823360 Revocation Notice For Failure to File An Annual Report 2021-05-19
202035886400 Annual Report 2020-03-04
201988300560 Annual Report 2019-03-07
201862401080 Annual Report 2018-04-17
201739137810 Annual Report 2017-03-29

Related by officers

JAMES A. BRIDEN, ESQ.

AMERICAN TOOL COMPANY DYNAMIC CONVERTING SYSTEMS, INC. AMERICAN CLIMATE TECHNOLOGY, INC. SYRKO INVESTMENTS, LLC Mediterranean & International Market, LLC EB PROPERTIES, INC. A.T. MINI MARKET, INC. INDUSTRIAS ALIMENTICIAS EN SU PUNTO USA, INC. INTERSTATE RELOCATION SERVICES, INC. New England Brickmaster Windows & Exteriors, Inc.

FADI MANSOURATI MD

INTEGRA COMMUNITY CARE NETWORK, LLC

Related by address

No related companies by address

Date of last update: 09 Oct 2024

Sources: Rhode Island Department of State

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