| Entity Name: | EVERGREEN MANOR RETIREMENT HOME, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 22 Sep 1995 (29 years ago) |
| Date of dissolution: | 26 Sep 2014 (10 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 26 Sep 2014 (10 years ago) |
| Document Number: | P95000073910 |
| FEI/EIN Number | 65-0627559 |
| Address: | 3297 STATE ROAD 580, SAFTY HARBOR, FL 34695 |
| Mail Address: | 3297 STATE ROAD 580, SAFTY HARBOR, FL 34695 |
| ZIP code: | 34695 |
| County: | Pinellas |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366697153 | 2008-11-21 | 2008-11-21 | 3297 STATE ROAD 580, SAFETY HARBOR, FL, 346954929, US | 3297 STATE ROAD 580, SAFETY HARBOR, FL, 346954929, US | |||||||||||||||||
|
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| Phone | +1 727-724-3776 |
Authorized person
| Name | YEE-CHUN TAN KAPUSINSKY |
| Role | ADMINISTRATOR |
| Phone | 7274802180 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL8760 |
| State | FL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| Simpson, Tesha | Agent | 3297 State Road 580, Safety Harbor, FL 34695 |
| Name | Role | Address |
|---|---|---|
| KAPUSINSKY, YEE-CHUN | Owner | 3348 LAKE SHORE LANE, CLEARWATER, FL 33761 |
| Name | Role | Address |
|---|---|---|
| BROSS, JENNIFER | Administrator | 414 PINEWOOD DRIVE, OLDSMAR, FL 34677 |
| Name | Role | Address |
|---|---|---|
| BROSS, JENNIFER | RA | 414 PINEWOOD DRIVE, OLDSMAR, FL 34677 |
| SIMPSON, TESHA | RA | 736 BRITTANY PARK BLVD, TARPON SPRINGS, FL 34689 |
| Name | Role | Address |
|---|---|---|
| SIMPSON, TESHA | Co | 736 BRITTANY PARK BLVD, TARPON SPRINGS, FL 34689 |
| Name | Role | Address |
|---|---|---|
| SIMPSON, TESHA | administrator | 736 BRITTANY PARK BLVD, TARPON SPRINGS, FL 34689 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2014-09-26 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2013-06-12 | Simpson, Tesha | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2013-06-12 | 3297 State Road 580, Safety Harbor, FL 34695 | No data |
| CHANGE OF MAILING ADDRESS | 2010-03-06 | 3297 STATE ROAD 580, SAFTY HARBOR, FL 34695 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 1998-01-21 | 3297 STATE ROAD 580, SAFTY HARBOR, FL 34695 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2013-06-12 |
| ANNUAL REPORT | 2012-04-30 |
| ANNUAL REPORT | 2012-04-25 |
| ANNUAL REPORT | 2011-05-01 |
| ANNUAL REPORT | 2010-03-06 |
| ANNUAL REPORT | 2009-03-15 |
| ANNUAL REPORT | 2008-05-11 |
| ANNUAL REPORT | 2007-04-23 |
| ANNUAL REPORT | 2006-03-02 |
| ANNUAL REPORT | 2005-02-11 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
