| Entity Name: | FAIRGREEN ASSISTED LIVING, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 15 Mar 2004 (21 years ago) |
| Document Number: | P04000049511 |
| FEI/EIN Number | 200949437 |
| Address: | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL, 32168 |
| Mail Address: | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL, 32168 |
| ZIP code: | 32168 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1184059750 | 2013-09-13 | 2013-09-13 | 1150 WAYNE AVE, NEW SMYRNA BEACH, FL, 321686132, US | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL, 32168, US | |||||||||||||||||||||||||
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| Phone | +1 386-428-3018 |
| Fax | 3864287485 |
Authorized person
| Name | MRS. JESUSA H. KEPLER |
| Role | OWNER/ADMINISTRATOR |
| Phone | 3864283018 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL11072 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1150 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KEPLER JESUSA H | Agent | 1150 WAYNE AVE, NEW SMYRNA BEACH, FL, 32168 |
| Name | Role | Address |
|---|---|---|
| KEPLER JESUSA H | President | 1150 WAYNE AVE, NEW SMYRNA BEACH, FL, 32168 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G19000067845 | FAIRGREEN ASSISTED LIVING FACILITY INC. | EXPIRED | 2019-06-14 | 2024-12-31 | No data | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL, 32168 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2009-04-23 | 1150 WAYNE AVE, NEW SMYRNA BEACH, FL 32168 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2007-05-24 | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL 32168 | No data |
| CHANGE OF MAILING ADDRESS | 2007-05-24 | 1150 WAYNE AVE., NEW SMYRNA BEACH, FL 32168 | No data |
| REGISTERED AGENT NAME CHANGED | 2005-03-11 | KEPLER, JESUSA H | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-03-25 |
| ANNUAL REPORT | 2023-02-16 |
| ANNUAL REPORT | 2022-02-02 |
| ANNUAL REPORT | 2021-02-13 |
| ANNUAL REPORT | 2020-01-27 |
| ANNUAL REPORT | 2019-04-25 |
| ANNUAL REPORT | 2018-02-17 |
| ANNUAL REPORT | 2017-04-18 |
| ANNUAL REPORT | 2016-04-14 |
| ANNUAL REPORT | 2015-04-16 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
