| Entity Name: | THE CHILDREN'S PLACE AT HOME SAFE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 29 Jun 1979 (46 years ago) |
| Document Number: | 747926 |
| FEI/EIN Number | 591935485 |
| Address: | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461, US |
| Mail Address: | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461, US |
| ZIP code: | 33461 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1437143054 | 2005-09-09 | 2008-07-18 | 2840 6TH AVE S, LAKE WORTH, FL, 334614729, US | 2840 6TH AVE S, LAKE WORTH, FL, 334614729, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 561-383-9800 |
| Fax | 5613839854 |
Authorized person
| Name | MR. MATTHEW LADIKA |
| Role | CHEIF EXECUTIVE OFFICER |
| Phone | 5613839800 |
Taxonomy
| Taxonomy Code | 322D00000X - Emotionally Disturbed Childrens' Residential Treatment Facility |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 070522502 |
| State | FL |
| Issuer | MEDICAID |
| Number | 070522504 |
| State | FL |
| Issuer | MEDICAID |
| Number | 070522501 |
| State | FL |
| Issuer | MEDICAID |
| Number | 070795300 |
| State | FL |
| Issuer | MEDICAID |
| Number | 070522500 |
| State | FL |
| Issuer | MEDICAID |
| Number | 070522503 |
| State | FL |
| Issuer | MEDICAID |
| Number | 912205200 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| THE CHILDREN'S PLACE AT HOME SAFE FLEXIBLE BENEFIT PLAN | 2010 | 591935485 | 2013-01-25 | THE CHILDREN'S PLACE AT HOME SAFE INC | 91 | |||||||||||||||||||||||||||||||||||||||||||||||||
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| Administrator’s EIN | 591935485 |
| Plan administrator’s name | THE CHILDREN'S PLACE AT HOME SAFE INC |
| Plan administrator’s address | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
| Administrator’s telephone number | 5613839800 |
Number of participants as of the end of the plan year
| Active participants | 101 |
| Retired or separated participants receiving benefits | 2 |
Signature of
| Role | Plan administrator |
| Date | 2013-01-25 |
| Name of individual signing | BILLY VAN EE |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2013-01-25 |
| Name of individual signing | PATRICIA JUNIOR |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 501 |
| Effective date of plan | 1993-08-01 |
| Business code | 624200 |
| Sponsor’s telephone number | 5613839800 |
| Plan sponsor’s DBA name | HOME SAFE, INC |
| Plan sponsor’s mailing address | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
| Plan sponsor’s address | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
Plan administrator’s name and address
| Administrator’s EIN | 591935485 |
| Plan administrator’s name | THE CHILDREN'S PLACE AT HOME SAFE INCE |
| Plan administrator’s address | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
| Administrator’s telephone number | 5613839800 |
Number of participants as of the end of the plan year
| Active participants | 93 |
Signature of
| Role | Plan administrator |
| Date | 2011-01-24 |
| Name of individual signing | PATRICIA JUNIOR |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| LADIKA MATTHEW | Agent | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
| Name | Role | Address |
|---|---|---|
| BRUNO MICHAEL J | Secretary | 132 ROYAL PALM WAY, PALM BEACH, FL, 33480 |
| Name | Role | Address |
|---|---|---|
| MOTEN TARRA L | President | 1000 PALM BEACH INTERNATIONAL AIRPORT, WEST PALM BEACH, FL, 33406 |
| Name | Role | Address |
|---|---|---|
| GONNELLO LAWRENCE | Pastor | 3399 PGA BLVD, PALM BEACH GARDENS, FL, 33410 |
| Name | Role | Address |
|---|---|---|
| VARGAS ROBERTO | Member | 505 S. FLAGLER DRIVE, WEST PALM BEACH, FL, 33401 |
| Name | Role | Address |
|---|---|---|
| PEREZ VAL | Treasurer | 591 EVERNIA STREET, WEST PALM BEACH, FL, 33401 |
| Name | Role | Address |
|---|---|---|
| Stoops Aggie J | Vice President | 521 S. Ocean Blvd., Delray Beach, FL, 33483 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000016209 | HOMESAFE | ACTIVE | 2012-02-15 | 2027-12-31 | No data | 2840 SIXTH AVENUE SOUTH, LAKE WORTH, FL, 33461 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| MERGER | 2014-12-12 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. MERGER NUMBER 900000147259 |
| MERGER | 1998-12-24 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. MERGER NUMBER 300000026113 |
| MERGER NAME CHANGE | 1998-12-24 | THE CHILDREN'S PLACE AT HOME SAFE, INC. | CORPORATE NAME CHANGE WAS A RESULT OF A MERGER. |
| NAME CHANGE AMENDMENT | 1992-10-30 | THE CHILDREN'S PLACE AND CONNOR'S NURSERY, INC. | No data |
| EVENT CONVERTED TO NOTES | 1992-06-22 | No data | No data |
| REINSTATEMENT | 1986-12-17 | No data | No data |
| INVOLUNTARILY DISSOLVED | 1986-11-14 | No data | No data |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
