| Entity Name: | PETERSON ASSISTED LIVING FACILITY INC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 15 Oct 2003 (21 years ago) |
| Date of dissolution: | 01 Oct 2004 (20 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 01 Oct 2004 (20 years ago) |
| Document Number: | P03000114117 |
| Address: | 1622 SILVER ST, JACKSONVILLE, FL, 32206 |
| Mail Address: | 1622 SILVER ST, JACKSONVILLE, FL, 32206 |
| ZIP code: | 32206 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1447697628 | 2013-05-29 | 2013-05-29 | 1622 SILVER ST, JACKSONVILLE, FL, 322064446, US | 1622 SILVER ST, JACKSONVILLE, FL, 322064446, US | |||||||||||||||||||||||||
|
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| Phone | +1 904-356-3022 |
| Fax | 9043509165 |
Authorized person
| Name | MS. LAVERNE JACKSON |
| Role | DIRECTOR OF OPERATION |
| Phone | 9043563922 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL8638 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 140750300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PETERSON MARY | Agent | 1622 SILVER ST, JACKSONVILLE, FL, 32206 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2004-10-01 | No data | No data |
| Name | Date |
|---|---|
| Domestic Profit | 2003-10-15 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
