| Entity Name: | SENIORS IN SERVICE OF TAMPA BAY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 20 Mar 1984 (41 years ago) |
| Document Number: | N02055 |
| FEI/EIN Number | 592422975 |
| Address: | 1306 W SLIGH AVE, TAMPA, FL, 33604, US |
| Mail Address: | 1306 W SLIGH AVE, TAMPA, FL, 33604, US |
| ZIP code: | 33604 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1669781258 | 2010-09-29 | 2010-09-29 | 1306 W. SLIGH AVENUE, TAMPA, FL, 336045902, US | 1306 W. SLIGH AVENUE, TAMPA, FL, 336045902, US | |||||||||||||||||||||||||
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| Phone | +1 813-932-5228 |
| Fax | 8139329604 |
Authorized person
| Name | MRS. GRACE H. PUTERMAN |
| Role | PRESIDENT & CEO |
| Phone | 8139325228 |
Taxonomy
| Taxonomy Code | 372600000X - Adult Companion |
| License Number | 5776 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 672457400 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| EMPLOYEE BENEFIT PLAN OF SENIORS IN SERVICE OF TAMPA BAY, INC. | 2022 | 592422975 | 2023-09-06 | SENIORS IN SERVICE OF TAMPA BAY, INC. | 28 | |||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2023-09-06 |
| Name of individual signing | HEATHER ROGERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1990-01-01 |
| Business code | 624200 |
| Sponsor’s telephone number | 8139325228 |
| Plan sponsor’s address | 1306 W SLIGH AVE, TAMPA, FL, 336045902 |
Signature of
| Role | Plan administrator |
| Date | 2022-10-07 |
| Name of individual signing | HEATHER ROGERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1990-01-01 |
| Business code | 624200 |
| Sponsor’s telephone number | 8139325228 |
| Plan sponsor’s address | 1306 W SLIGH AVE, TAMPA, FL, 336045902 |
Signature of
| Role | Plan administrator |
| Date | 2021-06-25 |
| Name of individual signing | HEATHER ROGERS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1990-01-01 |
| Business code | 624200 |
| Sponsor’s telephone number | 8139325228 |
| Plan sponsor’s address | 1306 W SLIGH AVE, TAMPA, FL, 336045902 |
Signature of
| Role | Plan administrator |
| Date | 2020-07-30 |
| Name of individual signing | HEATHER ROGERS |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| Ingles Robin | Agent | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Name | Role | Address |
|---|---|---|
| Choundas Marina AEsq. | Director | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Heizer David | Director | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Bergman Tracie | Director | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Fudge Daphne Dr. | Director | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Hall Mark | Director | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Name | Role | Address |
|---|---|---|
| Ingles Robin | Officer | 1306 W SLIGH AVE, TAMPA, FL, 33604 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT AND NAME CHANGE | 1997-09-29 | SENIORS IN SERVICE OF TAMPA BAY, INC. | No data |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
