| Entity Name: | SELAH-FOREST LAKE MANOR, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Inactive |
| Date Filed: | 08 Sep 2010 (14 years ago) |
| Date of dissolution: | 29 Apr 2015 (10 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 29 Apr 2015 (10 years ago) |
| Document Number: | L10000093988 |
| FEI/EIN Number | 27-3357187 |
| Address: | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 |
| Mail Address: | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 |
| ZIP code: | 32082 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1316281215 | 2012-11-15 | 2012-11-15 | 252 FOREST LAKE BLVD, DAYTONA BEACH, FL, 321198106, US | 252 FOREST LAKE BLVD, DAYTONA BEACH, FL, 321198106, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 386-760-7174 |
| Fax | 3867607812 |
Authorized person
| Name | MR. ALAN DANIEL PARRISH |
| Role | MANAGER |
| Phone | 9045431818 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL8869 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 003453400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Filippone, William T | Agent | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 |
| Name | Role |
|---|---|
| SELAH SENIORCARE II, LLC | Manager |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000089637 | FOREST LAKE MANOR | EXPIRED | 2012-09-12 | 2017-12-31 | No data | 50 A1A N. SUITE 110, PONTE VEDRA BEACH, FL, 32082 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2015-04-29 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2015-02-04 | Filippone, William T | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-01-08 | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-08 | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-01-08 | 115 Professional Drive, Suite 101, PONTE VEDRA BEACH, FL 32082 | No data |
| REINSTATEMENT | 2012-04-06 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2011-09-23 | No data | No data |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2015-04-29 |
| ANNUAL REPORT | 2015-02-04 |
| ANNUAL REPORT | 2014-01-08 |
| ANNUAL REPORT | 2013-01-16 |
| REINSTATEMENT | 2012-04-06 |
| Florida Limited Liability | 2010-09-08 |
Date of last update: 24 Jan 2025
Sources: Florida Department of State
