| Entity Name: | FOUNTAIN INN NURSING & REHABILITATION CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Inactive |
| Date Filed: | 24 Oct 2014 (10 years ago) |
| Date of dissolution: | 24 Sep 2024 (4 months ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 24 Sep 2024 (4 months ago) |
| Document Number: | N14000009925 |
| FEI/EIN Number | 47-2180518 |
| Mail Address: | 485 N. KELLER ROAD, MAITLAND, FL, 32751, US |
| Address: | 4501 Waterman Way, Tavares, FL, 32778, US |
| ZIP code: | 32778 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1437640471 | 2018-05-25 | 2023-11-27 | 900 HOPE WAY, ALTAMONTE SPRINGS, FL, 327141502, US | 4501 WATERMAN WAY, TAVARES, FL, 32778, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 407-975-3000 |
| Fax | 4079753090 |
| Phone | +1 352-609-4000 |
Authorized person
| Name | MR. DAVID RODMAN |
| Role | ASST SECRETARY OF THE BOARD |
| Phone | 4079753011 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 100964700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BROMME JEFFREY S | Agent | 900 HOPE WAY, ALTAMONTE SPRINGS, FL, 32714 |
| Name | Role | Address |
|---|---|---|
| ADDISCOTT LYNN | Assi | 900 HOPE WAY, ALTAMONTE SPRINGS, FL, 32714 |
| RATHBUN PAUL C | Assi | 900 HOPE WAY, ALTAMONTE SPRINGS, FL, 32714 |
| Vincent Haney | Assi | 900 Hope Way, Altamonte Springs, FL, 32714 |
| Saunders Michael | Assi | 900 Hope Way, Altamonte Springs, FL, 32714 |
| Name | Role | Address |
|---|---|---|
| Stiltz Bryan | Chairman | 900 HOPE WAY, ALTAMONTE SPRINGS, FL, 32714 |
| Name | Role | Address |
|---|---|---|
| Rodman David L | Director | 485 N. Keller Road, Maitland, FL, 32751 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G18000104364 | ADVENTHEALTH CARE CENTER WATERMAN | ACTIVE | 2018-09-21 | 2028-12-31 | No data | 4501 WATERMAN WAY, TAVARES, FL, 32778 |
| G18000095466 | ADVENTHEALTH TRANSITIONAL CARE WATERMAN | EXPIRED | 2018-08-27 | 2023-12-31 | No data | 405 WATERMAN WAY, TAVARES, FL, 32778 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2024-09-24 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2020-12-11 | BROMME, JEFFREY S | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-02-01 | 4501 Waterman Way, Tavares, FL 32778 | No data |
| CHANGE OF MAILING ADDRESS | 2015-12-04 | 4501 Waterman Way, Tavares, FL 32778 | No data |
| Name | Date |
|---|---|
| Voluntary Dissolution | 2024-10-18 |
| Voluntary Dissolution | 2024-09-24 |
| ANNUAL REPORT | 2024-07-12 |
| AMENDED ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2023-01-19 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-04-24 |
| Reg. Agent Change | 2020-12-11 |
| ANNUAL REPORT | 2020-06-22 |
| ANNUAL REPORT | 2019-04-18 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
