| Field | Data |
|---|---|
| EIN | 84-5088439 |
| Case Number | EO-2020097-000129 |
| Form 1023-EZ version | 12018 |
| Eligibility Worksheet | 1 |
| Organization Name | OBSIDIAN HEALTH I INC |
| Organization’s Mailing Address | 2604 SELLERS LANE |
| City | WILMINGTON |
| State | DE |
| ZIP | 19802 |
| Accounting period End | 12 |
| Primary contact name | MIESHIA CLARK |
| Primary contact phone | [Hidden] |
| Primary contact phone extension | [Hidden] |
| Primary contact fax | [Hidden] |
| User fee submitted | $275.00 |
MIESHIA CLARK
CHIEF MEDICAL OFFICER
2604 SELLERS LANE
WILMINGTON DE 19802
UTHMAN CLARK
TREASURER
502 WELCH STREET
ATHENS AL 35611
IMAN BLACKWELL
CHIEF OPERATING OFFICE
2201 CARLTON LANE
WILMINGTON DE 19810
| Organization’s website | OBSIDIANHEALTHINC.ORG |
|---|---|
| Organization’s email | DR.MIESHIA@OBSIDIANHEALTHINC.ORG |
| Organization Incorporated | Yes |
| Organization trust | No |
| Necessary Organizing Documents | Yes |
| Organization Incorporation Date | 3/19/2020 |
| Organization Incorporation State | DE |
| Contains Limitation | Yes |
| Does not expressly empower | Yes |
| Contains dissolution | Yes |
| National Taxonomy of Exempt Entities (NTEE) code | E32 - Ambulatory Health Center, Community Clinic |
| Organization’s purpose | Charitable: Yes Religious: No Educational: No Scientific: No Literary: No Public Safety: No Amateur Sports: No Cruelty Prevention: No |
| Qualify For Exemption | No |
| Legislation influence | No |
| Compensation of Officer director trustee | No |
| Donation of funds | Yes |
| Conducting Activities Outside of United States | No |
| Financial transactions with officers | No |
| Unrelated Gross Income $1,000 or More | No |
| Gaming Activity | No |
| Disaster relief assistance | No |
| One Third Support Public | Yes |
| One Third Support Gifts | No |
| Benefit of College | No |
| Private Foundation 508(e) | No |
| Seeking Retroactive Reinstatement | No |
| Seeking Section 7 Reinstatement | No |
| Correctness Declaration | Yes |
| Signature Name | MIESHIA CLARK |
| Signature Title | CHIEF MEDICAL OFFICER |
| Signature Date | 4/2/2020 |
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