| Entity Name: | SOVEREIGN HEALTHCARE OF MACCLENNY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Co. |
| Status: | Active |
| Date Filed: | 15 Jul 2003 (22 years ago) |
| Document Number: | M03000002342 |
| FEI/EIN Number | 200185142 |
| Mail Address: | 101 Sunnytown Road, Casselberry, FL, 32707, US |
| Address: | 755 South 5th Street, Macclenny, FL, 32063, US |
| ZIP code: | 32063 |
| County: | Baker |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1720075351 | 2005-09-29 | 2014-09-24 | 5887 GLENRIDGE DR, SUITE 150, ATLANTA, GA, 303285574, US | 755 S 5TH ST, MACCLENNY, FL, 320632685, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 404-574-2100 |
| Fax | 4045742105 |
| Phone | +1 904-259-4873 |
| Fax | 9042595381 |
Authorized person
| Name | MR. R. MARK CRONQUIST |
| Role | MANAGER |
| Phone | 4045742100 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | SNF1222096 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | VA |
| Number | V573P-6392 |
| Issuer | MEDICAID |
| Number | 026351600 |
| State | FL |
| Name | Role |
|---|---|
| COGENCY GLOBAL INC. | Agent |
| Name | Role |
|---|---|
| SOUTHERN HEALTHCARE MANAGEMENT, LLC | Manager |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G09048900145 | MACCLENNY NURSING AND REHAB CENTER | ACTIVE | 2009-02-17 | 2029-12-31 | No data | 755 SOUTH 5TH STREET, MACCLENNY, FL, 32063 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2017-03-30 | 755 South 5th Street, Macclenny, FL 32063 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-07-07 | 115 North Calhoun St., Suite 4, Tallahassee, FL 32301 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-14 | 755 South 5th Street, Macclenny, FL 32063 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-03-09 |
| ANNUAL REPORT | 2022-02-24 |
| ANNUAL REPORT | 2021-03-18 |
| ANNUAL REPORT | 2020-04-14 |
| ANNUAL REPORT | 2019-03-21 |
| ANNUAL REPORT | 2018-04-27 |
| ANNUAL REPORT | 2017-03-30 |
| ANNUAL REPORT | 2016-03-30 |
| ANNUAL REPORT | 2015-01-14 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
