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  5. STILL WATERS OF LAKE CITY, INC.

STILL WATERS OF LAKE CITY, INC.

Company Details

Entity Name: STILL WATERS OF LAKE CITY, INC.
Jurisdiction: FLORIDA
Filing Type: Florida Not For Profit Corporation
Status: Inactive
Date Filed: 18 Apr 2001 (24 years ago)
Date of dissolution: 21 Apr 2022 (3 years ago)
Last Event: VOLUNTARY DISSOLUTION
Event Date Filed: 21 Apr 2022 (3 years ago)
Document Number: N01000002771
FEI/EIN Number 59-3717525
Address: 217 SW Dyal Ave, LAKE CITY, FL 32024
Mail Address: c/o 217 SW Dyal Ave, LAKE CITY, FL 32024
ZIP code: 32024
County: Columbia
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1104160027 2012-11-15 2012-11-15 507 NW HALL OF FAME DR, LAKE CITY, FL, 320554835, US 507 NW HALL OF FAME DR, LAKE CITY, FL, 320554835, US

Contacts
Phone +1 386-755-6560
Fax 3866285018

Authorized person
Name THREASA HYSELL
Role EXECUTIVE DIRECTOR
Phone 3867556560

Taxonomy
Taxonomy Code 310400000X - Assisted Living Facility
License Number AL9472
State FL
Is Primary Yes
Taxonomy Code 311500000X - Alzheimer Center (Dementia Center)
License Number AL9472
State FL
Is Primary No
Taxonomy Code 311ZA0620X - Adult Care Home Facility
License Number AL9472
State FL
Is Primary No
Taxonomy Code 385H00000X - Respite Care
License Number AL9472
State FL
Is Primary No

Other Provider Identifiers
Issuer MEDICAID WAIVER
Number 682130800
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
STILLWATERS 401(K) PLAN 2023 593717525 2024-09-13 STILL WATERS OF LAKE CITY, INC. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3867552525
Plan sponsor’s address 217 SW DYAL AVENUE, LAKE CITY, FL, 32024

Signature of
Role Plan administrator
Date 2024-09-13
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2022 593717525 2023-10-15 STILL WATERS OF LAKE CITY, INC. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3864876109
Plan sponsor’s address CO 217 SW DYAL AVE, LAKE CITY, FL, 32024

Signature of
Role Plan administrator
Date 2023-10-15
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2020 593717525 2021-09-29 STILL WATERS OF LAKE CITY, INC. 30
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3864876109
Plan sponsor’s address 217 SW DYAL AVENUE, LAKE CITY, FL, 32024

Signature of
Role Plan administrator
Date 2021-09-29
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2019 593717525 2020-07-09 STILL WATERS OF LAKE CITY, INC. 23
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3864876109
Plan sponsor’s address 217 SW DYAL AVE, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2020-07-09
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2018 593717525 2019-09-18 STILL WATERS OF LAKE CITY, INC. 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3864876109
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2019-09-18
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2017 593717525 2018-06-19 STILL WATERS OF LAKE CITY, INC. 27
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3864876109
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2018-06-19
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2016 593717525 2017-06-19 STILL WATERS OF LAKE CITY, INC. 35
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3867556560
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2017-06-19
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2015 593717525 2016-06-17 STILL WATERS OF LAKE CITY, INC. 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3867556560
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2016-06-17
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2014 593717525 2015-06-12 STILL WATERS OF LAKE CITY, INC. 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3867556560
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2015-06-12
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature
STILLWATERS 401(K) PLAN 2013 593717525 2014-06-26 STILL WATERS OF LAKE CITY, INC. 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2011-02-01
Business code 623000
Sponsor’s telephone number 3867556560
Plan sponsor’s address 507 NW HALL OF FAME DR, LAKE CITY, FL, 32055

Signature of
Role Plan administrator
Date 2014-06-26
Name of individual signing WANDA GREEN
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
HYSELL, THREASA M Agent 1661 SW ST JAMES CT., LAKE CITY, FL 32025

President

Name Role Address
JOHNS, LONNIE RJR President 2512 SW Family Road, Lulu, FL 32061

Director

Name Role Address
JOHNS, LONNIE RJR Director 2512 SW Family Road, Lulu, FL 32061
ELLIS, EVERETT W Director PO BOX 3384, LAKE CITY, FL 32056
HYSELL, THREASA Director 1661 SW ST JAMES CT, LAKE CITY, FL 32025

Vice President

Name Role Address
ELLIS, EVERETT W Vice President PO BOX 3384, LAKE CITY, FL 32056

Treasurer

Name Role Address
HYSELL, THREASA Treasurer 1661 SW ST JAMES CT, LAKE CITY, FL 32025

Events

Event Type Filed Date Value Description
VOLUNTARY DISSOLUTION 2022-04-21 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2020-09-25 No data No data
CHANGE OF PRINCIPAL ADDRESS 2019-05-03 217 SW Dyal Ave, LAKE CITY, FL 32024 No data
CHANGE OF MAILING ADDRESS 2019-05-03 217 SW Dyal Ave, LAKE CITY, FL 32024 No data
REGISTERED AGENT ADDRESS CHANGED 2003-04-17 1661 SW ST JAMES CT., LAKE CITY, FL 32025 No data

Documents

Name Date
VOLUNTARY DISSOLUTION 2022-04-21
ANNUAL REPORT 2019-05-03
ANNUAL REPORT 2018-04-25
ANNUAL REPORT 2017-04-27
ANNUAL REPORT 2016-04-21
ANNUAL REPORT 2015-04-28
ANNUAL REPORT 2014-04-25
ANNUAL REPORT 2013-04-29
ANNUAL REPORT 2012-04-18
ANNUAL REPORT 2011-03-21

Related by officers

HYSELL, THREASA M

SUWANNEE RIVER COVE, LLC THE DREAMS CENTER, INC.

JOHNS, LONNIE RJR

SUWANNEE RIVER COVE, LLC THE DREAMS CENTER, INC.

HYSELL, THREASA

THE DREAMS CENTER, INC.

Related by address

No related companies by address

Date of last update: 31 Jan 2025

Sources: Florida Department of State

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