| Entity Name: | JOHN KNOX VILLAGE OF TAMPA BAY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Not For Profit Corporation |
| Status: | Inactive |
| Date Filed: | 11 Sep 1979 (45 years ago) |
| Date of dissolution: | 23 Sep 2022 (2 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 23 Sep 2022 (2 years ago) |
| Document Number: | 748876 |
| FEI/EIN Number | 58-1377711 |
| Address: | 4100 E. FLETCHER AVENUE, TAMPA, FL 33613 |
| Mail Address: | 4100 E. FLETCHER AVENUE, TAMPA, FL 33613 |
| ZIP code: | 33613 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| Type | Company Name | Company Number | State |
|---|---|---|---|
| Headquarter of | JOHN KNOX VILLAGE OF TAMPA BAY, INC., NEW YORK | 626109 | NEW YORK |
| Headquarter of | JOHN KNOX VILLAGE OF TAMPA BAY, INC., NEW YORK | 708173 | NEW YORK |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1760479901 | 2005-10-03 | 2014-11-07 | 4100 E. FLETCHER AVE, TAMPA, FL, 336134863, US | 4100 E. FLETCHER AVE, TAMPA, FL, 336134863, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 813-632-2455 |
| Fax | 8136322388 |
Authorized person
| Name | MS. LISA VICARIO LYONS |
| Role | EXECUTIVE DIRECTOR |
| Phone | 8136322391 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL4110 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | SNF1260095 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 021028500 |
| State | FL |
| Issuer | BLUECROSS BLUESHIELD |
| Number | K68 |
| State | FL |
| Name | Role |
|---|---|
| BAYCARE HEALTH SYSTEM, INC. | Agent |
| Name | Role | Address |
|---|---|---|
| GUY, KIMBERLY | Director | 3001 W. DR. MARTIN LUTHER KING JR. BLVD., TAMPA, FL 33607 |
| Waters, Glenn | Director | 2985 Drew Street, Clearwater, FL 33759 |
| Inzina, Tommy | Director | 2985 Drew Street, Clearwater, FL 33759 |
| Name | Role | Address |
|---|---|---|
| Polo, Janice | Directo | 2985 Drew Street, Clearwater, FL 33759 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G13000111841 | JOHN KNOX VILLAGE MED CENTER | EXPIRED | 2013-11-08 | 2018-12-31 | No data | 4100 E FLETCHER AVE N, TAMPA, FL, 33613 |
| G11000044429 | ST. JOSEPH'S JOHN KNOX VILLAGE OF TAMPA BAY | EXPIRED | 2011-05-09 | 2016-12-31 | No data | 3001 W. DR. MARTIN LUTHER KING BLVD, ATTENTION: ADMINISTRATION, TAMPA, FL, 33607, US |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-03-08 | BAYCARE HEALTH SYSTEM, INC. | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-03-08 | ATTENTION: LEGAL SERVICES DEPARTMENT, 2985 DREW STREET, CLEARWATER, FL 33759 | No data |
| AMENDED AND RESTATEDARTICLES | 2014-07-02 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-04-02 | 4100 E. FLETCHER AVENUE, TAMPA, FL 33613 | No data |
| CHANGE OF MAILING ADDRESS | 2014-04-02 | 4100 E. FLETCHER AVENUE, TAMPA, FL 33613 | No data |
| AMENDED AND RESTATEDARTICLES | 1997-12-02 | No data | No data |
| AMENDMENT | 1997-08-29 | No data | No data |
| AMENDED AND RESTATEDARTICLES | 1991-01-30 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2021-03-02 |
| ANNUAL REPORT | 2020-02-03 |
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-04-16 |
| ANNUAL REPORT | 2017-04-24 |
| ANNUAL REPORT | 2016-03-08 |
| ANNUAL REPORT | 2015-04-27 |
| Amended and Restated Articles | 2014-07-02 |
| ANNUAL REPORT | 2014-04-02 |
| AMENDED ANNUAL REPORT | 2013-11-13 |
Date of last update: 05 Feb 2025
Sources: Florida Department of State
