| Entity Name: | PALM LAKE VILLAGE HOUSING CORPORATION |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 07 Jul 1986 (39 years ago) |
| Document Number: | N15843 |
| FEI/EIN Number | 592691849 |
| Address: | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| Mail Address: | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| ZIP code: | 33778 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1184962003 | 2013-01-28 | 2019-09-05 | 3800 62ND AVE N, PINELLAS PARK, FL, 337816055, US | 3800 62ND AVE N, PINELLAS PARK, FL, 337816055, US | |||||||||||||||||||||||
|
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| Phone | +1 727-489-6440 |
Authorized person
| Name | LISA ELLIOTT |
| Role | ADMINISTRATOR |
| Phone | 7274896440 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL10314 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 001645100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| GILMORE RICARDO LESQ. | Agent | FIFTH THIRD PLAZA, 201 EAST KENNEDY BLVD, TAMPA, FL, 33602 |
| Name | Role | Address |
|---|---|---|
| MINEO WAYNE | Director | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| TOMCZAK ALEN | Director | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| Name | Role | Address |
|---|---|---|
| FIREBAUGH CHLOE | Vice President | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| Name | Role | Address |
|---|---|---|
| BRICKFIELD NEIL | Gene | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| Name | Role | Address |
|---|---|---|
| HICKEY VERONICA | President | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G23000112501 | MAGNOLIA GARDENS ALF | ACTIVE | 2023-09-13 | 2028-12-31 | No data | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| G22000024554 | CRYSTAL LAKES MANOR | ACTIVE | 2022-03-01 | 2027-12-31 | No data | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| G22000024553 | PALM LAKE VILLAGE | ACTIVE | 2022-03-01 | 2027-12-31 | No data | 11479 ULMERTON ROAD, LARGO, FL, 33778 |
| G17000091589 | MAGNOLIA GARDENS ALF | EXPIRED | 2017-08-18 | 2022-12-31 | No data | 3800 62ND AVE N, PINELLAS PARK, FL, 33781 |
| G11000011969 | CRYSTAL LAKES MANOR | EXPIRED | 2011-01-31 | 2016-12-31 | No data | 4100 62ND AVE N, PINELLAS PARK, FL, 33781 |
| G11000011973 | MAGNOLIA GARDENS ALF | EXPIRED | 2011-01-31 | 2016-12-31 | No data | 3800 62ND AVE N, PINELLAS PARK, FL, 33781 |
| G11000011964 | PALM LAKE VILLAGE | EXPIRED | 2011-01-31 | 2016-12-31 | No data | 1515 COUNTY ROAD ONE, DUNEDIN, FL, 34698 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDED AND RESTATEDARTICLES | 2014-05-19 | No data | No data |
| AMENDMENT | 1987-07-29 | No data | No data |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
