| Entity Name: | SUMMERVILLE AT MANDARIN, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Company |
| Status: | Active |
| Date Filed: | 21 Jun 2005 (20 years ago) |
| Document Number: | M05000003563 |
| FEI/EIN Number | 20-3013975 |
| Address: | 111 Westwood Place, Suite 400, Brentwood, TN 37027 |
| Mail Address: | 111 Westwood Place, Suite 400, Brentwood, TN 37027 |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114253945 | 2009-10-29 | 2016-05-13 | 6737 W WASHINGTON ST, SUITE 2300, MILWAUKEE, WI, 532145647, US | 10790 OLD SAINT AUGUSTINE RD, JACKSONVILLE, FL, 322571078, US | |||||||||||||||||||||||
|
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| Phone | +1 904-260-0800 |
Authorized person
| Name | BRYAN RICHARDSON |
| Role | EVP, CHIEF ADMIN. OFFICER |
| Phone | 6155648131 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL8789 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 0118156-00 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| Baier, Lucinda M | Chief Executive Officer | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| Baier, Lucinda M | President | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| White, Chad C. | EVP AND SECRETARY | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| KUSSOW, DAWN L | Chief Financial Officer | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| Kussow, Dawn | Executive Vice President | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| RICCI, BENJAMIN J | Director | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| RICCI, BENJAMIN J | Vice President | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role |
|---|---|
| SUMMERVILLE SENIOR LIVING, INC. | Managing Member |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000116926 | BROOKDALE MANDARIN | EXPIRED | 2014-11-20 | 2024-12-31 | No data | 10790 OLD ST. AUGUSTINE ROAD, JACKSONVILLE, FL, 32257 |
| G08149900374 | EMERITUS AT MANDARIN | EXPIRED | 2008-05-28 | 2013-12-31 | No data | 3131 ELLIOTT AVENUE, SUITE 500, SEATTLE, WA, 98121 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2017-04-29 | 111 Westwood Place, Suite 400, Brentwood, TN 37027 | No data |
| CHANGE OF MAILING ADDRESS | 2015-04-13 | 111 Westwood Place, Suite 400, Brentwood, TN 37027 | No data |
| REGISTERED AGENT NAME CHANGED | 2007-09-07 | CORPORATION SERVICE COMPANY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2007-09-07 | 1201 HAYS STREET, TALLAHASSEE, FL 32301-2525 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-04 |
| ANNUAL REPORT | 2023-04-24 |
| ANNUAL REPORT | 2022-04-20 |
| ANNUAL REPORT | 2021-04-26 |
| ANNUAL REPORT | 2020-06-15 |
| ANNUAL REPORT | 2019-04-29 |
| ANNUAL REPORT | 2018-04-26 |
| ANNUAL REPORT | 2017-04-29 |
| ANNUAL REPORT | 2016-04-04 |
| ANNUAL REPORT | 2015-04-13 |
Date of last update: 04 Jan 2025
Sources: Florida Department of State
