efile Public Visual Render
ObjectId: 202221369349310142 - Submission: 2022-05-16
TIN: 58-1594191
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
20
Open to Public Inspection
Name of the organization
BALLAD HEALTH FOUNDATION
Employer identification number
58-1594191
Part I
Identification of Disregarded Entities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Total income
(e)
End-of-year assets
(f)
Direct controlling
entity
Part II
Identification of Related Tax-Exempt Organizations.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization
(b)
Primary activity
(c)
Legal domicile (state
or foreign country)
(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))
(f)
Direct controlling
entity
(g)
Section 512(b)(13) controlled entity?
Yes
No
(1)
MOUNTAIN STATES HEALTH ALLIANCE
303 MED TECH PARKWAY SUITE 220
JOHNSON CITY
,
TN
37604
62-0476282
HOSPITAL SYSTEM
TN
501(C)(3)
LINE 3
BALLAD HEALTH
No
(2)
MSHA AUXILIARY
400 N STATE OF FRANKLIN ROAD
JOHNSON CITY
,
TN
37604
58-1418345
SUPPORTING ORGANIZATION
TN
501(C)(3)
LINE 12A, I
MOUNTAIN STATES HEALTH ALLIANCE
No
(3)
SMYTH COUNTY COMMUNITY HOSPITAL
245 MEDICAL PARK DRIVE
MARION
,
VA
24354
54-0794913
HOSPITAL
VA
501(C)(3)
LINE 3
MOUNTAIN STATES HEALTH ALLIANCE
No
(4)
NORTON COMMUNITY HOSPITAL
100 15TH STREET NW
NORTON
,
VA
24273
54-0566029
HOSPITAL
VA
501(C)(3)
LINE 3
MOUNTAIN STATES HEALTH ALLIANCE
No
(5)
DICKENSON COMMUNITY HOSPITAL
312 HOSPITAL DRIVE
CLINTWOOD
,
VA
24228
77-0599553
HOSPITAL
VA
501(C)(3)
LINE 3
WELLMONT HEALTH SYSTEM
No
(6)
JOHNSTON MEMORIAL HOSPITAL
16000 JOHNSTON MEMORIAL DRIVE
ABINGDON
,
VA
24211
54-0544705
HOSPITAL
VA
501(C)(3)
LINE 3
N/A
No
(7)
ABINGDON PHYSICIAN PARTNERS
16000 JOHNSTON MEMORIAL DRIVE
ABINGDON
,
VA
24211
20-5485346
MEDICAL SERVICES
VA
501(C)(3)
LINE 12A, I
JOHNSTON MEMORIAL HOSPITAL INC
No
(8)
BALLAD HEALTH
303 MED TECH PARKWAY SUITE 220
JOHNSON CITY
,
TN
37604
61-1771290
SUPPORTING ORGANIZATION
TN
501(C)(3)
LINE 12B, II
N/A
No
(9)
EAST TN HEALTHCARE HOLDINGS INC
203 GRAY COMMONS CIRCLE
GRAY
,
TN
37615
81-5475903
OPIOID TREATMENT
TN
501(C)(3)
LINE 3
MOUNTAIN STATES HEALTH ALLIANCE
No
(10)
WELLMONT HEALTH SYSTEM
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1636465
HOSPITAL SYSTEM
TN
501(C)(3)
LINE 3
BALLAD HEALTH
No
(11)
WELLMONT HAWKINS CO MEMORIAL HOSP
851 LOCUST STREET
ROGERSVILLE
,
TN
37857
62-1816368
HOSPITAL
TN
501(C)(3)
LINE 3
WELLMONT HEALTH SYSTEM
No
(12)
TAKOMA REGIONAL HOSPITAL INC DBA GREENEVILLE COMMUNITY HOSPITAL
1420 TUSCULUM BOULEVARD
GREENEVILLE
,
TN
37745
51-0603966
HOSPITAL
TN
501(C)(3)
LINE 3
WELLMONT HEALTH SYSTEM
No
(13)
WELLMONT CARDIOLOGY SERVICES
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
26-3557623
MEDICAL SERVICES
TN
501(C)(3)
LINE 10
WELLMONT HEALTH SYSTEM
No
(14)
WELLMONT MEDICAL ASSOCIATES
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
27-0898372
MEDICAL SERVICES
TN
501(C)(3)
LINE 7
WELLMONT HEALTH SYSTEM
No
(15)
WELLMONT MADISON HOUSE
2000 GREENWAY STREET
KINGSPORT
,
TN
37660
62-1308216
ASSISTED LIVING
TN
501(C)(3)
LINE 10
WELLMONT HEALTH SYSTEM
No
(16)
WELLMONT WEXFORD HOUSE
2421 N JOHN B DENNIS HWY
KINGSPORT
,
TN
37660
58-1859039
NURSING HOME
TN
501(C)(3)
LINE 10
WELLMONT HEALTH SYSTEM
No
(17)
WELLMONT IMAGING SERVICES INC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
86-1103148
HEALTHCARE
TN
501(C)(3)
LINE 12A, I
WELLMONT HEALTH SYSTEM
No
(18)
WELLMONT SLEEP SERVICES
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
27-3777167
MEDICAL SERVICES
TN
501(C)(3)
LINE 3
WELLMONT HEALTH SYSTEM
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2020
Page 2
Schedule R (Form 990) 2020
Page
2
Part III
Identification of Related Organizations Taxable as a Partnership.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
(1)
REHAB HOSPITAL OF BRISTOL LLC
123 NORTH STREET
BRISTOL
,
VA
24201
20-5612001
REHAB SERVICES
VA
N/A
No
No
(2)
GREENEVILLE PHYSICIAN SERVICES LLC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
45-5070419
MEDICAL SERVICES
TN
N/A
No
No
(3)
EMMAUS COMMUNITY HEALTHCARE PLLC
6070 HWY 11E
PINEY FLATS
,
TN
37686
20-0577483
MEDICAL SERVICES
TN
N/A
No
No
(4)
MEDICAL SPECIALISTS OF JC LLC
2528 WESLEY STREET SUITE 2
JOHNSON CITY
,
TN
37601
27-2199037
MEDICAL SERVICES
TN
N/A
No
No
(5)
EAST TN AMBULATORY SURGERY CENTER
701 MED TECH PARKWAY SUITE 100
JOHNSON CITY
,
TN
37604
62-1787537
MEDICAL SERVICES
TN
N/A
No
No
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
(b)
Primary activity
(c)
Legal
domicile
(state or foreign
country)
(d)
Direct controlling
entity
(e)
Type of entity
(C corp, S corp,
or trust)
(f)
Share of total income
(g)
Share of end-of-year
assets
(h)
Percentage
ownership
(i)
Section 512(b)(13) controlled entity?
Yes
No
(1)
BLUE RIDGE MEDICAL MANAGEMENT CORP
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1490616
MEDICAL SERVICES
TN
N/A
C
No
(2)
MEDISERVE MEDICAL EQUIPMENT
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1212286
DURABLE MEDICAL EQUIPMENT CO.
TN
N/A
C
No
(3)
MOUNTAIN STATES PROPERTIES
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1845895
PROPERTY MANAGEMENT
TN
N/A
C
No
(4)
MOUNTAIN STATES PHYSICIAN GROUP
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1700412
MEDICAL SERVICES
TN
N/A
C
No
(5)
COMMUNITY HOME CARE INC
1490 PARK AVENUE NW SUITE B
NORTON
,
VA
24273
54-1453810
DURABLE MEDICAL EQUIPMENT CO.
VA
N/A
C
No
(6)
WILSON PHARMACY INC
PO BOX 5289
JOHNSON CITY
,
TN
37604
62-0329587
PHARMACY
TN
N/A
C
No
(7)
CRESTPOINT HEALTH INSURANCE COMPANY
509 MED TECH PARKWAY SUITE 100
JOHNSON CITY
,
TN
37604
62-0381170
INSURANCE
TN
N/A
C
No
(8)
WELLMONT INC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1320035
MEDICAL SERVICES
TN
N/A
C
No
(9)
WELLMONT COLLECTIONS INC
2004 AMERICAN WAY SUITE 101
KINGSPORT
,
TN
37660
62-1325938
BUSINESS SERVICES
TN
N/A
C
No
(10)
MEDICAL MALL PHARMACY INC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1565006
MEDICAL SERVICES
TN
N/A
C
No
(11)
WELLMONT PHYSICIAN SERVICES
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1567353
MEDICAL SERVICES
TN
N/A
C
No
(12)
WPS PROVIDERS INC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
20-5564642
MEDICAL SERVICES
TN
N/A
C
No
(13)
WELLMONT HEALTH SERVICES INC
1905 AMERICAN WAY
KINGSPORT
,
TN
37660
62-1254373
MEDICAL SERVICES
TN
N/A
C
No
(14)
NOLICHUCKEY MANAGEMENT SVCS INC
1420 TUSCULUM BOULEVARD
GREENEVILLE
,
TN
37745
62-1776681
MEDICAL SERVICES
TN
N/A
C
No
(15)
BALLAD VENTURES LLC
400 N STATE OF FRANKLIN RD
JOHNSON CITY
,
TN
37604
84-4214681
INVESTMENTS
TN
N/A
C
No
(16)
WELLMONT INSURANCE CO SPC LT
1905 AMERICAN WAY
GRAND CAYMON
,
KYI-1203
CJ
98-1195624
INSURANCE
CJ
N/A
C
No
Schedule R (Form 990) 2020
Page 3
Schedule R (Form 990) 2020
Page
3
Part V
Transactions With Related Organizations.
Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note.
Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1
During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a
Receipt of
(i)
interest,
(ii)
annuities,
(iii)
royalties, or
(iv)
rent from a controlled entity
.....................
1a
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
d
Loans or loan guarantees to or for related organization(s)
............................
1d
No
e
Loans or loan guarantees by related organization(s)
............................
1e
No
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
No
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
No
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
Yes
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
Yes
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
Yes
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
Yes
r
Other transfer of cash or property to related organization(s)
............................
1r
No
s
Other transfer of cash or property from related organization(s)
............................
1s
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved
Schedule R (Form 990) 2020
Page 4
Schedule R (Form 990) 2020
Page
4
Part VI
Unrelated Organizations Taxable as a Partnership.
Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity
(b)
Primary activity
(c)
Legal domicile
(state or foreign
country)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(e)
Are all partners
section
501(c)(3)
organizations?
(f)
Share of total income
(g)
Share of
end-of-year
assets
(h)
Disproprtionate allocations?
(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2020
Page 5
Schedule R (Form 990) 2020
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
Schedule R (Form 990) 2020
Additional Data
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