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  5. Avalon Nursing Home, Inc.

Avalon Nursing Home, Inc.

Company Details

Name: Avalon Nursing Home, Inc.
Jurisdiction: Rhode Island
Entity type: Domestic Profit Corporation
Status: Activ
Date of Organization in Rhode Island: 17 Mar 1964 (61 years ago)
Identification Number: 000001677
ZIP code: 02889
County: Kent County
Principal Address: 57 STOKES STREET, WARWICK, RI, 02889-3425, USA
Purpose: AN INSTITUTION FOR THE BOARD AND CARE AND TREATMENT OF AGED, SICK AND CONVALESENT PEOPLE
NAICS: 623110 - Nursing Care Facilities (Skilled Nursing Facilities)

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1891776522 2005-11-09 2020-01-21 57 STOKES ST, WARWICK, RI, 028893425, US 57 STOKES ST, WARWICK, RI, 028893425, US

Contacts
Phone +1 401-738-1200
Fax 4017389430

Authorized person
Name MR. DAVID STEPHEN KOWALIK
Role ASSISTANT ADMINISTRATOR
Phone 4017381200

Taxonomy
Taxonomy Code 314000000X - Skilled Nursing Facility
License Number N446
State RI
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 4105060
State RI

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2023 050305151 2024-10-15 AVALON NURSING HOME, INC. 37
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2024-10-15
Name of individual signing CHAD CARROLL
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2022 050305151 2023-10-04 AVALON NURSING HOME, INC. 37
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2023-10-04
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2021 050305151 2023-10-04 AVALON NURSING HOME, INC. 41
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2023-10-04
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2021 050305151 2022-10-11 AVALON NURSING HOME, INC. 39
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2022-10-11
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2020 050305151 2021-10-04 AVALON NURSING HOME, INC. 40
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2021-10-04
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2019 050305151 2020-10-01 AVALON NURSING HOME, INC. 38
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2020-10-01
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2018 050305151 2019-07-16 AVALON NURSING HOME, INC. 36
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2019-07-16
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2017 050305151 2018-10-12 AVALON NURSING HOME, INC. 34
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2018-10-12
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2016 050305151 2017-08-14 AVALON NURSING HOME, INC. 42
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2017-08-14
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
AVALON NURSING HOME, INC. EMPLOYEE RETIREMENT PLAN 2015 050305151 2016-10-17 AVALON NURSING HOME, INC. 39
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2016-10-17
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2015/10/16/20151016064945P030036189341001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2015-10-16
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2014/07/15/20140715105732P040040472785001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2014-07-15
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2013/07/15/20130715071147P030388033729001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Signature of
Role Plan administrator
Date 2013-07-15
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2012/06/12/20120612075634P030002982582001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Plan administrator’s name and address
Administrator’s EIN 050305151
Plan administrator’s name AVALON NURSING HOME, INC.
Plan administrator’s address 57 STOKES STREET, WARWICK, RI, 02889
Administrator’s telephone number 4017381200

Signature of
Role Plan administrator
Date 2012-06-12
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature
File https://efast2-filings-public.s3.amazonaws.com/prd/2011/10/03/20111003121328P040047420359001.pdf
Three-digit plan number (PN) 001
Effective date of plan 2010-01-01
Business code 623000
Sponsor’s telephone number 4017381200
Plan sponsor’s address 57 STOKES STREET, WARWICK, RI, 02889

Plan administrator’s name and address
Administrator’s EIN 050305151
Plan administrator’s name AVALON NURSING HOME, INC.
Plan administrator’s address 57 STOKES STREET, WARWICK, RI, 02889
Administrator’s telephone number 4017381200

Signature of
Role Plan administrator
Date 2011-10-03
Name of individual signing DAVID KOWALIK
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
LISA J. KOWALIK Agent 57 STOKES STREET, WARWICK, RI, 02889, USA

PRESIDENT

Name Role Address
DAVID KOWALIK PRESIDENT 54 ORMSBY AVE WARWICK, RI 02886 USA

Filings

Number Name File Date
202455384870 Annual Report 2024-06-06
202339780800 Annual Report 2023-07-26
202337976160 Revocation Notice For Failure to File An Annual Report 2023-06-19
202214419270 Annual Report 2022-04-11
202193430390 Annual Report 2021-03-02
202037228000 Annual Report 2020-04-06
201989500040 Annual Report 2019-03-29
201856589750 Annual Report 2018-01-23
201729674750 Annual Report 2017-01-09
201589802490 Annual Report 2015-12-29

Related by officers

LISA J. KOWALIK

AVACORP, INC. J. TUCKER MEASURING, INC.

Related by address

No related companies by address

Date of last update: 05 Oct 2024

Sources: Rhode Island Department of State

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