| Entity Name: | 12170 CORTEZ BOULEVARD OPERATIONS LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 18 Nov 2011 (13 years ago) |
| Last Event: | CORPORATE MERGER |
| Event Date Filed: | 01 Feb 2012 (13 years ago) |
| Document Number: | L11000131349 |
| FEI/EIN Number | 30-0706977 |
| Address: | 850 CONCOURSE PKWY, STE 250, MAITLAND, FL 32751 |
| Mail Address: | 1040 CROWN POINTE PKWY STE 600, ATLANTA, GA 30338-4741 |
| ZIP code: | 32751 |
| County: | Orange |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1497024269 | 2011-12-22 | 2023-11-27 | 12170 CORTEZ BLVD, BROOKSVILLE, FL, 346135578, US | 12170 CORTEZ BLVD, BROOKSVILLE, FL, 346135578, US | |||||||||||||||||||||||||
|
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| Phone | +1 352-597-5100 |
| Fax | 3525975020 |
Authorized person
| Name | KENNETH USSERY |
| Role | VP |
| Phone | 4075711550 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | SNF130470973 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 005987700 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role |
|---|---|
| EPSILON HEALTH CARE PROPERTIES, LLC | MEMBER |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G12000012174 | SPRING HILL HEALTH AND REHABILITATION CENTER | ACTIVE | 2012-02-03 | 2027-12-31 | No data | 1040 CROWN POINTE PARKWAY, SUITE 600, ATLANTA, GA, 30338 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-23 | 850 CONCOURSE PKWY, STE 250, MAITLAND, FL 32751 | No data |
| CHANGE OF MAILING ADDRESS | 2018-06-19 | 850 CONCOURSE PKWY, STE 250, MAITLAND, FL 32751 | No data |
| REGISTERED AGENT NAME CHANGED | 2012-03-20 | CORPORATION SERVICE COMPANY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-03-20 | 1201 HAYS STREET, TALLAHASSEE, FL 32301-2525 | No data |
| MERGER | 2012-02-01 | No data | CORPORATION WAS A MERGER RESULT. TOTAL NUMBER OF QUALIFIED CORPORATION(S) INVOLVED WAS 1. MERGER NUMBER 100000119981 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-23 |
| ANNUAL REPORT | 2023-04-25 |
| ANNUAL REPORT | 2022-04-28 |
| ANNUAL REPORT | 2021-04-21 |
| ANNUAL REPORT | 2020-04-20 |
| ANNUAL REPORT | 2019-04-21 |
| ANNUAL REPORT | 2018-04-19 |
| ANNUAL REPORT | 2017-04-17 |
| AMENDED ANNUAL REPORT | 2016-07-14 |
| ANNUAL REPORT | 2016-04-19 |
| Inspection Nr | Report ID | Date Opened | Site Address | |||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 339482986 | 0420600 | 2013-11-13 | 12170 CORTEZ BOULEVARD, BROOKSVILLE, FL, 34613 | |||||||||||||||||||||||||||||||||||||||||||||||
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| Type | Complaint |
| Activity Nr | 861567 |
| Safety | Yes |
| Health | Yes |
Violation Items
| Citation ID | 01001 |
| Citaton Type | Other |
| Standard Cited | 19040029 B03 |
| Issuance Date | 2013-12-13 |
| Abatement Due Date | 2013-12-19 |
| Current Penalty | 900.0 |
| Initial Penalty | 900.0 |
| Final Order | 2014-01-14 |
| Nr Instances | 1 |
| Nr Exposed | 20 |
| FTA Current Penalty | 0.0 |
| Citation text line | 29 CFR 1904.29(b)(3): Each recordable injury or illness was not entered on the OSHA 300 Log and/or an incident report (OSHA Form 301 or equivalent) within seven (7) calendar days of receiving information that a recordable injury or illness has occurred: a. At the site - recordable injuries for 2013 were not maintained on OSHA 300 logs. Violation observed on or about 11/13/13. |
Date of last update: 22 Feb 2025
Sources: Florida Department of State
