| Entity Name: | BLACK CREEK SUPPORTS AND SERVICES INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 16 Oct 2012 (12 years ago) |
| Date of dissolution: | 22 Sep 2023 (a year ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 22 Sep 2023 (a year ago) |
| Document Number: | P12000087201 |
| FEI/EIN Number | 46-1200718 |
| Address: | 225 COLLEGE DR#66146, ORANGE PARK, FL, 32065, US |
| Mail Address: | 225 COLLEGE DR#66146, ORANGE PARK, FL, 32065, US |
| ZIP code: | 32065 |
| County: | Clay |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902214174 | 2014-07-31 | 2014-07-31 | 1700 LISMORE CT, MIDDLEBURG, FL, 320686703, US | 1700 LISMORE CT, MIDDLEBURG, FL, 320686703, US | |||||||||||||||||||||||||
|
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| Phone | +1 904-449-2699 |
| Fax | 9043752019 |
Authorized person
| Name | SHIELA BRYANT BUTLER |
| Role | PRESIDENT |
| Phone | 9044492699 |
Taxonomy
| Taxonomy Code | 253Z00000X - In Home Supportive Care Agency |
| License Number | 232967 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 008143400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BUTLER SHIELA B | Agent | 225 COLLEGE DR#66146, ORANGE PARK, FL, 32065 |
| Name | Role | Address |
|---|---|---|
| BUTLER SHIELA B | Officer | 225 COLLEGE DR#66146, ORANGE PARK, FL, 32065 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2023-09-22 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2022-01-28 | BUTLER, SHIELA B | No data |
| REINSTATEMENT | 2022-01-28 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-03-09 | 225 COLLEGE DR#66146, ORANGE PARK, FL 32065 | No data |
| CHANGE OF MAILING ADDRESS | 2016-03-09 | 225 COLLEGE DR#66146, ORANGE PARK, FL 32065 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-03-09 | 225 COLLEGE DR#66146, ORANGE PARK, FL 32065 | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2022-01-28 |
| ANNUAL REPORT | 2020-06-05 |
| ANNUAL REPORT | 2019-04-22 |
| ANNUAL REPORT | 2018-04-16 |
| ANNUAL REPORT | 2017-04-23 |
| AMENDED ANNUAL REPORT | 2016-04-29 |
| ANNUAL REPORT | 2016-03-09 |
| ANNUAL REPORT | 2015-03-11 |
| ANNUAL REPORT | 2014-03-14 |
| ANNUAL REPORT | 2013-03-20 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
