| Entity Name: | PALM COAST ALF MANAGEMENT, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 04 Mar 2019 (6 years ago) |
| Last Event: | LC NAME CHANGE |
| Event Date Filed: | 14 Aug 2019 (5 years ago) |
| Document Number: | L19000060767 |
| FEI/EIN Number | 83-3940683 |
| Address: | 269 KIPLING CT, LAKE MARY, FL, 32746, UN |
| Mail Address: | 269 KIPLING CT, LAKE MARY, FL, 32746, UN |
| ZIP code: | 32746 |
| County: | Seminole |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922617505 | 2020-07-29 | 2021-05-20 | 269 KIPLING CT, LAKE MARY, FL, 327464124, US | 3830 OLD KINGS ROAD, PALM COAST, FL, 32137, US | |||||||||||||||||||||||||||
|
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| Phone | +1 407-202-0046 |
| Phone | +1 386-307-5445 |
Authorized person
| Name | MR. DERICK WAYNE DEETER |
| Role | MANAGER |
| Phone | 4072020046 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | ASSISTED LIVING FACILITY LICENSE |
| Number | 13591 |
| State | FL |
| Issuer | MEDICAID |
| Number | 110284500 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DEETER DERICK | Agent | 269 KIPLING CT, LAKE MARY, FL, 32746 |
| Name | Role | Address |
|---|---|---|
| DEETER DERICK | Manager | 269 KIPLING CT, LAKE MARY, FL, 32746 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000145131 | GOLD CHOICE PALM COAST | ACTIVE | 2020-11-11 | 2025-12-31 | No data | 269 KIPLING CT, LAKE MARY, FL, 32746 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2025-01-15 | 4009 W 1st Street, Sanford, Fl 32771 UN | No data |
| CHANGE OF MAILING ADDRESS | 2025-01-15 | 4009 W 1st Street, Sanford, Fl 32771 UN | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2025-01-15 | 4009 W 1st St, Sanford, FL 32771 | No data |
| LC NAME CHANGE | 2019-08-14 | PALM COAST ALF MANAGEMENT, LLC | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-15 |
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-01-20 |
| ANNUAL REPORT | 2022-05-02 |
| ANNUAL REPORT | 2021-02-22 |
| ANNUAL REPORT | 2020-01-07 |
| LC Name Change | 2019-08-14 |
| Florida Limited Liability | 2019-03-04 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
