| Entity Name: | COUNTRY LIVING ASSISTED CARE CENTER, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 18 Dec 2007 (17 years ago) |
| Document Number: | P07000132858 |
| FEI/EIN Number | 261588160 |
| Address: | 1762 SW ARCH ST., PORT SAINT LUCIE, FL, 34953 |
| Mail Address: | 1762 SW ARCH ST., PORT SAINT LUCIE, FL, 34953 |
| ZIP code: | 34953 |
| County: | St. Lucie |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1417135682 | 2008-02-09 | 2008-10-31 | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 349531558, US | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 349531558, US | |||||||||||||||||||||||||
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| Phone | +1 772-621-8211 |
| Fax | 7726218211 |
Authorized person
| Name | CAROL ANN CAMMARSANA |
| Role | ADM |
| Phone | 7726261150 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL11331 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDWAIVER |
| Number | 692697596 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| EDGETT CHRISTINE | Agent | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 34953 |
| Name | Role | Address |
|---|---|---|
| EDGETT DAVID C | President | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 34953 |
| Name | Role | Address |
|---|---|---|
| EDGETT CHRISTINE A | Vice President | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 34953 |
| Name | Role | Address |
|---|---|---|
| EDGETT CHRISTINE A | Treasurer | 1762 SW ARCH ST, PORT SAINT LUCIE, FL, 34953 |
| Name | Role | Address |
|---|---|---|
| CAMMARASANA CAROL A | Secretary | 1762 SW Arch St, PORT SAINT LUCIE, FL, 34953 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2010-04-20 | 1762 SW ARCH ST., PORT SAINT LUCIE, FL 34953 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2010-04-20 | 1762 SW ARCH ST, PORT SAINT LUCIE, FL 34953 | No data |
| REGISTERED AGENT NAME CHANGED | 2008-04-30 | EDGETT, CHRISTINE | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-03 |
| ANNUAL REPORT | 2023-03-31 |
| ANNUAL REPORT | 2022-04-05 |
| ANNUAL REPORT | 2021-04-20 |
| ANNUAL REPORT | 2020-06-04 |
| ANNUAL REPORT | 2019-04-08 |
| ANNUAL REPORT | 2018-04-12 |
| ANNUAL REPORT | 2017-04-06 |
| ANNUAL REPORT | 2016-04-01 |
| ANNUAL REPORT | 2015-04-02 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
