| Entity Name: | SUMMERVILLE AT CARROLLWOOD, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Company |
| Status: | Inactive |
| Date Filed: | 21 Jun 2005 (20 years ago) |
| Date of dissolution: | 29 Sep 2023 (a year ago) |
| Last Event: | WITHDRAWAL |
| Event Date Filed: | 29 Sep 2023 (a year ago) |
| Document Number: | M05000003566 |
| FEI/EIN Number | 20-3014229 |
| Address: | 111 Westwood Place, Suite 400, Brentwood, TN 37027 |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922218361 | 2007-05-23 | 2016-06-13 | 6737 W WASHINGTON ST STE 2300, MILWAUKEE, WI, 532145650, US | 13550 SOUTH VILLAGE DRIVE, TAMPA, FL, 33618, US | |||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 414-918-5000 |
| Fax | 9258668468 |
| Phone | +1 813-908-5300 |
| Fax | 8139085304 |
Authorized person
| Name | BYRAN RICHARDSON |
| Role | EVP, CHIEF ADMIN. OFFICER |
| Phone | 6155648131 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| Is Primary | No |
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL9134 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 311500000X - Alzheimer Center (Dementia Center) |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 0111609-00 |
| 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 |
|---|---|---|
| FISCHER, LAURA E | Director | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| RICCI, BENJAMIN J | Director | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Name | Role | Address |
|---|---|---|
| FISCHER, LAURA E | Vice President | 111 Westwood Place, Suite 400 Brentwood, TN 37027 |
| Leskowicz, Joanne | Vice President | 6737 W Washington Street, Suite 2300 MILWAUKEE, WI 53214 |
| RICCI, BENJAMIN J | Vice 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 | 6737 W WASHINGTON ST STE 2300, MILWAUKEE, WI 53214 |
| Name | Role | Address |
|---|---|---|
| Leskowicz, Joanne | Secretary | 6737 W Washington Street, Suite 2300 MILWAUKEE, WI 53214 |
| Name | Role |
|---|---|
| SUMMERVILLE SENIOR LIVING, INC. | Managing Member |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G14000117986 | BROOKDALE CARROLLWOOD | EXPIRED | 2014-11-24 | 2019-12-31 | No data | 3131 ELLIOTT AVE STE 500, SEATTLE, WA, 98121 |
| G09054900646 | EMERITUS AT CARROLLWOOD | EXPIRED | 2009-02-23 | 2014-12-31 | No data | 3131 ELLIOTT AVE., SUITE 500, SEATTLE, WA, 98121 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| WITHDRAWAL | 2023-09-29 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2017-04-29 | 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 |
|---|---|
| WITHDRAWAL | 2023-09-29 |
| 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
