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Collinsville Nursing Home, Inc.

Details

Name: Collinsville Nursing Home, Inc.
Jurisdiction: Alabama
Legal type: Domestic Corporation
Status: Exists
Date of registration: 06 Oct 1970 (54 years ago) (Companies founded in October 1970)
Entity Number: 000-004-555
Register Number: 000004555
ZIP code: 35961 (Companies in De Kalb, 35961)
County: De Kalb
Place of Formation: DeKalb County
Principal Address: COLLINSVILLE, AL
Registered Office Street Address: 685 NORTH VALLEY AVECOLLINSVILLE, AL 35961
Authorized Capital: $15,000
Paid Share Capital: $3,000

Activities NURSING HOME

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1467406298 2006-05-19 2013-02-08 PO BOX 310, COLLINSVILLE, AL, 359610310, US 685 NORTH VALLEY AVE, COLLINSVILLE, AL, 35961, US

Contacts
Phone +1 256-524-2117
Fax 2565242035

Authorized person
Name MR. JAMES RANDALL COKER JR.
Role ADMINISTRATOR
Phone 2565242117

Taxonomy
Taxonomy Code 314000000X - Skilled Nursing Facility
License Number 12525
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 4754120S
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
COLLINSVILLE NURSING HOME, INC. 401(K) PLAN 2023 630630902 2024-10-14 COLLINSVILLE NURSING HOME, INC. 177
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1992-01-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s address 685 NORTH VALLEY AVE, COLLINSVILLE, AL, 359613304

Signature of
Role Plan administrator
Date 2024-10-14
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2024-10-14
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME WELFARE BENEFIT PLAN 2022 630630902 2024-04-16 COLLINSVILLE NURSING HOME, INC. 166
Three-digit plan number (PN) 502
Effective date of plan 1999-07-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 159

Signature of
Role Plan administrator
Date 2024-04-15
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2024-04-15
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME GROUP HEALTH CARE PLAN 2022 630630902 2024-03-15 COLLINSVILLE NURSING HOME, INC. 130
File View Page
Three-digit plan number (PN) 501
Effective date of plan 1997-04-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 126

Signature of
Role Plan administrator
Date 2024-03-15
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2024-03-15
Name of individual signing JON WOODARD
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME WELFARE BENEFIT PLAN 2021 630630902 2023-04-18 COLLINSVILLE NURSING HOME, INC. 170
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1999-07-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 166

Signature of
Role Plan administrator
Date 2023-04-18
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2023-04-18
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME GROUP HEALTH CARE PLAN 2021 630630902 2022-12-31 COLLINSVILLE NURSING HOME, INC. 138
File View Page
Three-digit plan number (PN) 501
Effective date of plan 1997-04-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 130

Signature of
Role Plan administrator
Date 2022-12-31
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2022-12-31
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME WELFARE BENEFIT PLAN 2020 630630902 2022-04-15 COLLINSVILLE NURSING HOME, INC. 195
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1999-07-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 170

Signature of
Role Plan administrator
Date 2022-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2022-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME GROUP HEALTH CARE PLAN 2020 630630902 2021-12-30 COLLINSVILLE NURSING HOME, INC. 153
File View Page
Three-digit plan number (PN) 501
Effective date of plan 1997-04-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 35961
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 138

Signature of
Role Plan administrator
Date 2021-12-30
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-12-30
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME WELFARE BENEFIT PLAN 2019 630630902 2021-04-15 COLLINSVILLE NURSING HOME, INC. 202
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1999-07-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 195

Signature of
Role Plan administrator
Date 2021-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME GROUP HEALTH CARE PLAN 2019 630630902 2021-03-15 COLLINSVILLE NURSING HOME, INC. 153
File View Page
Three-digit plan number (PN) 501
Effective date of plan 1997-04-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address PO BOX 310, COLLINSVILLE, AL, 359610310
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 153

Signature of
Role Plan administrator
Date 2021-03-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-03-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
COLLINSVILLE NURSING HOME WELFARE BENEFIT PLAN 2018 630630902 2020-04-15 COLLINSVILLE NURSING HOME, INC. 205
File View Page
Three-digit plan number (PN) 502
Effective date of plan 1999-07-01
Business code 623000
Sponsor’s telephone number 2565242117
Plan sponsor’s DBA name COLLINSVILLE HEALTH CARE AND REHAB
Plan sponsor’s mailing address P.O. BOX 310, COLLINSVILLE, AL, 35961
Plan sponsor’s address 685 NORTH VALLEY AVENUE, COLLINSVILLE, AL, 35961

Number of participants as of the end of the plan year
Active participants 202

Signature of
Role Plan administrator
Date 2020-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-04-15
Name of individual signing JAMES COKER
Valid signature Filed with authorized/valid electronic signature

Incorporator

Name Role
GRESSLER, H GEORGE Incorporator
GRESSLER, VERA A Incorporator
COKER, IRMA R GRESSLER Incorporator

Agent

Name Role
COKER, IRMA Agent

Events

Event Date Event Type Old Value New Value
1974-04-01 Capital Change $3,000 Authorized $3,000 Paid In $15,000 Authorized $3,000 Paid In

Related by officers

No related officers

Related by address

COLLINSVILLE, AL

Collinsville Milling Co., Inc. DeKalb County Development Company W. V. Graves & Company, Inc. The Peoples Bank of Collinsville Reclamation, Inc. Sarah Discount Company, Inc. Canyon Land Camping and Amusement Park, Inc. L & J Trucking, Inc. Collinsville Car Wash, Inc.

Date of last update: 30 Jul 2024

Sources: Alabama Secretary of State

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