| Entity Name: | MAGNOLIA RETIREMENT HOME, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Inactive |
| Date Filed: | 08 May 1996 (29 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | P96000041172 |
| FEI/EIN Number | 65-0672055 |
| Address: | 149 MAGNOLIA AVE, SEBRING, FL 33870 |
| Mail Address: | 149 MAGNOLIA AVE, SEBRING, FL 33870 |
| ZIP code: | 33870 |
| County: | Highlands |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1922307586 | 2011-03-22 | 2011-03-22 | 149 MAGNOLIA AVE, SEBRING, FL, 338703613, US | 149 MAGNOLIA AVE, SEBRING, FL, 338703613, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 863-382-2116 |
| Fax | 8633822117 |
Authorized person
| Name | MR. MANUEL M DOMISIW |
| Role | OWNER/ADMINISTRATOR |
| Phone | 8633822116 |
Taxonomy
| Taxonomy Code | 310400000X - Assisted Living Facility |
| License Number | AL4947 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3104A0625X - Assisted Living Facility (Mental Illness) |
| License Number | AL4947 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 140646900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| DOMISIW, MANUEL M | Agent | 149 MAGNOLIA AVE, SEBRING, FL 33870 |
| Name | Role | Address |
|---|---|---|
| DOMISIW, MANUEL M | Director | 17040 BRIDLEPATH CT, LUTZ, FL 33558 |
| DOMISIW, PRISCILLA C | Director | 17040 BRIDLEPATH CT, LUTZ, FL 33558 |
| Name | Role | Address |
|---|---|---|
| DOMISIW, DENNIS C | Officer | 149 MAGNOLIA AVENUE, SEBRING, FL 33870 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2018-07-31 |
| ANNUAL REPORT | 2017-04-25 |
| ANNUAL REPORT | 2016-04-14 |
| ANNUAL REPORT | 2015-04-22 |
| ANNUAL REPORT | 2014-03-18 |
| ANNUAL REPORT | 2013-04-30 |
| ANNUAL REPORT | 2012-04-13 |
| ANNUAL REPORT | 2011-03-22 |
| ANNUAL REPORT | 2010-04-28 |
| ANNUAL REPORT | 2009-03-25 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
