| Entity Name: | 3865 TAMPA ROAD, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 04 Jun 2001 (24 years ago) |
| Document Number: | M01000001250 |
| FEI/EIN Number | 061621885 |
| Address: | 101 EAST STATE STREET, KENNETT SQUARE, PA, 19348, US |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1487678132 | 2006-07-26 | 2018-03-23 | 101 SUN AVE NE, COMPLIANCE DEPARTMENT, ALBUQUERQUE, NM, 871094373, US | 3865 TAMPA RD, OLDSMAR, FL, 346773008, US | |||||||||||||||||||||||||||||
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| Phone | +1 505-468-5604 |
| Fax | 5054684681 |
| Phone | +1 813-855-4661 |
| Fax | 8138542129 |
Authorized person
| Name | MICHAEL THEODORE BERG |
| Role | VP AND ASST SECRETARY |
| Phone | 5054684742 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | SNF 1591096 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 025346400 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role |
|---|---|
| FLORIDA HOLDINGS III, LLC | Auth |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G13000026087 | WEST BAY OF TAMPA | EXPIRED | 2013-03-15 | 2018-12-31 | No data | 3865 TAMPA ROAD, OLDSMAR, FL, 34677 |
| G08336700033 | WEST BAY CARE AND REHABILITATION CENTER | EXPIRED | 2008-12-01 | 2013-12-31 | No data | 101 SUN AVE. NE, ALBUQUERQUE, NM, 87109 |
| G08325900247 | WEST BARY CARE AND REHABILITATION CENTER | EXPIRED | 2008-11-20 | 2013-12-31 | No data | 3865 TAMPA ROAD, OLDSMAR, FL, 34677 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| WITHDRAWAL | 2023-12-20 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
