| Entity Name: | COUNTRY CLUB LIVING, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 22 Jul 2003 (22 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 29 Nov 2021 (3 years ago) |
| Document Number: | P03000080320 |
| FEI/EIN Number | 200198480 |
| Address: | 16837 N. W. 91 STREET, HIALEAH, FL, 33018, US |
| Mail Address: | 16837 N. W. 91 STREET, HIALEAH, FL, 33018, US |
| ZIP code: | 33018 |
| County: | Miami-Dade |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1063535854 | 2007-04-09 | 2023-01-27 | 16837 N. W. 91 CT., MIAMI LAKES, FL, 33018, US | 16837 N. W. 91 CT., MIAMI LAKES, FL, 33018, US | |||||||||||||||||||||||||||||||
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| Phone | +1 305-549-8657 |
| Fax | 3058169996 |
Authorized person
| Name | YENEY SUAREZ I |
| Role | OWNER |
| Phone | 7867158902 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL10449 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 142170100 |
| State | FL |
| Issuer | MEDICAID |
| Number | 689009100 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SUAREZ YENEY | Agent | 16837 N. W. 91 STREET, HIALEAH, FL, 33018 |
| Name | Role | Address |
|---|---|---|
| SUAREZ YENEY | President | 16837 N. W. 91 Street, Hialeah, FL, 33018 |
| Name | Role | Address |
|---|---|---|
| SUAREZ YENEY | Vice President | 16837 N. W. 91 Street, Hialeah, FL, 33018 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G18000056812 | MIAMI LAKES RETIREMENT HOME | ACTIVE | 2018-05-08 | 2028-12-31 | No data | 16837 NW 91 CT, MIAMI LAKES, FL, 33018 |
| G14000074048 | MIAMI LAKES RETIREMENT HOME | EXPIRED | 2014-07-17 | 2019-12-31 | No data | 6791 ROYAL MELBOURNE DR, HIALEAH, FL, 33015 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2021-11-29 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2021-11-29 | 16837 N. W. 91 STREET, HIALEAH, FL 33018 | No data |
| REGISTERED AGENT NAME CHANGED | 2021-11-29 | SUAREZ, YENEY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-11-29 | 16837 N. W. 91 STREET, HIALEAH, FL 33018 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2013-04-15 | 16837 N. W. 91 STREET, HIALEAH, FL 33018 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-01-19 |
| ANNUAL REPORT | 2022-01-19 |
| Amendment | 2021-11-29 |
| ANNUAL REPORT | 2021-04-20 |
| ANNUAL REPORT | 2020-06-09 |
| ANNUAL REPORT | 2019-04-24 |
| ANNUAL REPORT | 2018-04-03 |
| ANNUAL REPORT | 2017-03-29 |
| ANNUAL REPORT | 2016-04-14 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
