| Entity Name: | STEPHENS MEMORIAL HOME, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 14 Jul 2000 (25 years ago) |
| Document Number: | P00000068597 |
| FEI/EIN Number | 593674615 |
| Address: | % BRENDA L. STEPHENS, 5805 DATIL PEPPER ROAD, ST. AUGUSTINE, FL, 32086 |
| Mail Address: | % BRENDA L. STEPHENS, 5805 DATIL PEPPER ROAD, ST. AUGUSTINE, FL, 32086 |
| ZIP code: | 32086 |
| County: | St. Johns |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1316381890 | 2013-04-26 | 2013-04-26 | 5805 DATIL PEPPER RD, SAINT AUGUSTINE, FL, 320865699, US | 5805 DATIL PEPPER RD, SAINT AUGUSTINE, FL, 320865699, US | |||||||||||||||||||||||||
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| Phone | +1 904-797-0294 |
| Fax | 9047976372 |
Authorized person
| Name | BRENDA STEPHENS |
| Role | OWNER/PROVIDER |
| Phone | 9047970294 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL10189 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 685603900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| STEPHENS BRENDA L | Agent | 5805 DATIL PEPPER ROAD, ST. AUGUSTINE, FL, 32086 |
| Name | Role | Address |
|---|---|---|
| STEPHENS BRENDA | President | 5805 DATIL PEPPER ROAD, SAINT AUGUSTINE, FL, 32086 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2006-02-17 | % BRENDA L. STEPHENS, 5805 DATIL PEPPER ROAD, ST. AUGUSTINE, FL 32086 | No data |
| CHANGE OF MAILING ADDRESS | 2006-02-17 | % BRENDA L. STEPHENS, 5805 DATIL PEPPER ROAD, ST. AUGUSTINE, FL 32086 | No data |
| REGISTERED AGENT NAME CHANGED | 2006-02-17 | STEPHENS, BRENDA L | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-03 |
| ANNUAL REPORT | 2023-02-06 |
| ANNUAL REPORT | 2022-02-18 |
| ANNUAL REPORT | 2021-02-04 |
| ANNUAL REPORT | 2020-03-17 |
| ANNUAL REPORT | 2019-02-07 |
| ANNUAL REPORT | 2018-01-16 |
| ANNUAL REPORT | 2017-01-06 |
| ANNUAL REPORT | 2016-01-26 |
| ANNUAL REPORT | 2015-01-10 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
