| Entity Name: | ADVANCE SAM CARE, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 16 Aug 2021 (3 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 27 Dec 2021 (3 years ago) |
| Document Number: | P21000073476 |
| FEI/EIN Number | 87-2078103 |
| Address: | 2101 VISTA PARKWAY, SUITE 200, WEST PALM BEACH, FL 33411 |
| Mail Address: | 2101 VISTA PARKWAY, SUITE 200, WEST PALM BEACH, FL 33411 |
| ZIP code: | 33411 |
| County: | Palm Beach |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1699462960 | 2023-04-18 | 2023-04-18 | 2101 VISTA PKWY STE 200, WEST PALM BEACH, FL, 334112706, US | 2101 VISTA PKWY STE 200, WEST PALM BEACH, FL, 334112706, US | |||||||||||||||||||||||
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| Phone | +1 561-228-7450 |
Authorized person
| Name | TIBAB DELISSER |
| Role | OWNER |
| Phone | 5612287450 |
Taxonomy
| Taxonomy Code | 251C00000X - Developmentally Disabled Services Day Training Agency |
| Is Primary | No |
| Taxonomy Code | 253Z00000X - In Home Supportive Care Agency |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 112869600 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DELISSER, TIBAB | Agent | 2101 VISTA PARKWAY, WEST PALM BEACH, FL 33411 |
| Name | Role | Address |
|---|---|---|
| ROSE, MICHAEL | Chief Executive Officer | 128 MONTEREY WAY, ROYAL PALM BEACH, FL 33411 UN |
| Name | Role | Address |
|---|---|---|
| ROSE, JONATHAN | Director | 2101 VISTA PARKWAY SUITE 200, WEST PALM BEACH, FL 33411 |
| Name | Role | Address |
|---|---|---|
| DELISSER, TIBAB | President | 2101 VISTA PARKWAY SUITE 200, WEST PALM BEACH, FL 33411 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2021-12-27 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2021-12-27 | 2101 VISTA PARKWAY, SUITE 200, WEST PALM BEACH, FL 33411 | No data |
| CHANGE OF MAILING ADDRESS | 2021-12-27 | 2101 VISTA PARKWAY, SUITE 200, WEST PALM BEACH, FL 33411 | No data |
| AMENDMENT | 2021-10-18 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2021-10-18 | DELISSER, TIBAB | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-10-18 | 2101 VISTA PARKWAY, WEST PALM BEACH, FL 33411 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-09 |
| ANNUAL REPORT | 2023-01-30 |
| ANNUAL REPORT | 2022-03-15 |
| Amendment | 2021-12-27 |
| Amendment | 2021-10-18 |
| Domestic Profit | 2021-08-16 |
Date of last update: 13 Jan 2025
Sources: Florida Department of State
