| Entity Name: | GREEN LIFE ASSISTED LIVING FACILITY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 21 Aug 2013 (11 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 05 Oct 2022 (2 years ago) |
| Document Number: | L13000118275 |
| FEI/EIN Number | 46-3483106 |
| Mail Address: | 11290 WALSINGHAM ROAD, LARGO, FL 33778 |
| Address: | 11290 Walsingham Road, Largo, FL 33778 |
| ZIP code: | 33778 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1124423470 | 2014-10-29 | 2015-03-05 | 840 SW 8TH ST, POMPANO BEACH, FL, 330608214, US | 840 SW 8TH ST, POMPANO BEACH, FL, 330608214, US | |||||||||||||||||||||||||
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| Phone | +1 855-331-6615 |
| Fax | 8556384902 |
Authorized person
| Name | MS. MARI CLARK |
| Role | CEO |
| Phone | 8139311433 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL12577 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 013937500 |
| State | FL |
| LEI number | Registered As | Jurisdiction Of Formation | General Category | Entity Status | Entity created at | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 549300WYXM0FIQ8M9M69 | L13000118275 | US-FL | GENERAL | ACTIVE | No data | |||||||||||||||||||
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| Legal | C/O CORPORATION COMPANY OF ORLANDO, 300 SOUTH ORANGE AVENUE, SUITE 1600 (BMJ), ORLANDO, US-FL, US, 32801 |
| Headquarters | 801 SW 10th Dr, Pompano Beach, US-FL, US, 33060 |
Registration details
| Registration Date | 2019-04-23 |
| Last Update | 2023-08-04 |
| Status | LAPSED |
| Next Renewal | 2020-04-21 |
| LEI Issuer | 5493001KJTIIGC8Y1R12 |
| Corroboration Level | FULLY_CORROBORATED |
| Data Validated As | L13000118275 |
| Name | Role | Address |
|---|---|---|
| Dandache, Molly Herrick | Agent | 11290 WALSINGHAM ROAD, LARGO, FL 33778 |
| Name | Role | Address |
|---|---|---|
| CLARK, MARISABEL | Manager | 3771 DARSTON ST., PALM HARBOR, FL 34685 |
| Name | Role | Address |
|---|---|---|
| CLARK, MARISABEL | Chief Executive Officer | 3771 DARSTON ST., PALM HARBOR, FL 34685 |
| Name | Role | Address |
|---|---|---|
| SCOTT, DANA D | MANAGER | 11290 WALSINGHAM ROAD, LARGO, FL 33778 |
| Name | Role | Address |
|---|---|---|
| SCOTT, DANA D | Chief Financial Officer | 11290 WALSINGHAM ROAD, LARGO, FL 33778 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2022-10-05 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2022-10-05 | Dandache, Molly Herrick | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-10-05 | 11290 WALSINGHAM ROAD, LARGO, FL 33778 | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2022-09-23 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-04-30 | 11290 Walsingham Road, Largo, FL 33778 | No data |
| CHANGE OF MAILING ADDRESS | 2019-03-27 | 11290 Walsingham Road, Largo, FL 33778 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-16 |
| ANNUAL REPORT | 2023-02-13 |
| REINSTATEMENT | 2022-10-05 |
| ANNUAL REPORT | 2021-04-30 |
| ANNUAL REPORT | 2020-06-30 |
| ANNUAL REPORT | 2019-05-01 |
| ANNUAL REPORT | 2018-03-30 |
| ANNUAL REPORT | 2017-04-28 |
| AMENDED ANNUAL REPORT | 2016-04-29 |
| ANNUAL REPORT | 2016-03-08 |
Date of last update: 22 Jan 2025
Sources: Florida Department of State
