| Entity Name: | SHADY LANE RETIREMENT HOME, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 13 Jan 2009 (16 years ago) |
| Date of dissolution: | 27 Sep 2024 (4 months ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2024 (4 months ago) |
| Document Number: | L09000003827 |
| FEI/EIN Number | 300589766 |
| Address: | 13814 amelia Pond Drive, Windermere, FL, 34786, US |
| Mail Address: | 13814 amelia Pond Drive, Windermere, FL, 34786, US |
| ZIP code: | 34786 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114253754 | 2009-11-01 | 2009-11-01 | 201 ROSEFIELD AVE, LEESBURG, FL, 347485014, US | 201 ROSEFIELD AVE, LEESBURG, FL, 347485014, US | |||||||||||||||||||||||||
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| Phone | +1 352-728-1559 |
| Fax | 3527281703 |
Authorized person
| Name | MR. SEGUNDO LIZARDO |
| Role | OWNER/ADMINISTRATOR |
| Phone | 3527281559 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL6001 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 2209282005070 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PATEL TEJESH | Agent | 201 ROSEFIELD AVENUE, LEESBURG, FL, 34748 |
| Name | Role | Address |
|---|---|---|
| PATEL TEJESH | Authorized Member | 201 ROSEFIELD AVENUE, LEESBURG, FL, 34748 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2024-09-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2023-07-24 | 13814 amelia Pond Drive, Windermere, FL 34786 | No data |
| CHANGE OF MAILING ADDRESS | 2023-07-24 | 13814 amelia Pond Drive, Windermere, FL 34786 | No data |
| REGISTERED AGENT NAME CHANGED | 2019-01-22 | PATEL, TEJESH | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-06-29 | 201 ROSEFIELD AVENUE, LEESBURG, FL 34748 | No data |
| LC AMENDMENT | 2018-06-29 | No data | No data |
| REINSTATEMENT | 2010-10-09 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2010-09-24 | No data | No data |
| LC AMENDMENT AND NAME CHANGE | 2009-05-13 | SHADY LANE RETIREMENT HOME, LLC | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2023-04-07 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-01-31 |
| ANNUAL REPORT | 2020-06-10 |
| ANNUAL REPORT | 2019-01-22 |
| LC Amendment | 2018-06-29 |
| ANNUAL REPORT | 2018-03-08 |
| ANNUAL REPORT | 2017-04-10 |
| ANNUAL REPORT | 2016-02-03 |
| ANNUAL REPORT | 2015-02-27 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
