| Entity Name: | TITUSVILLE NEUROLOGY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 25 Oct 2012 (12 years ago) |
| Date of dissolution: | 23 Sep 2016 (8 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 23 Sep 2016 (8 years ago) |
| Document Number: | L12000136547 |
| FEI/EIN Number | 46-1251920 |
| Mail Address: | PO Box 1947, TITUSVILLE, FL, 32781, US |
| Address: | 123 South Park Avenue, TITUSVILLE, FL, 32796, US |
| ZIP code: | 32796 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1508287715 | 2013-12-16 | 2014-01-27 | 123 S PARK AVE, TITUSVILLE, FL, 327963377, US | 123 S PARK AVE, TITUSVILLE, FL, 327963377, US | |||||||||||||||||||||
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| Phone | +1 321-383-0900 |
| Fax | 3213830024 |
Authorized person
| Name | DR. LEILA MARIA PATALLO |
| Role | OWNER/PHYSICIAN |
| Phone | 3213830900 |
Taxonomy
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 13868 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PATALLO LEILA M | Agent | 123 South Park Avenue, TITUSVILLE, FL, 32796 |
| Name | Role | Address |
|---|---|---|
| PATALLO LEILA M | Manager | 123 South Park Avenue, TITUSVILLE, FL, 32796 |
| JACQUET DELPHINE | Manager | 123 South Park Avenue, TITUSVILLE, FL, 32796 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2015-03-24 | 123 South Park Avenue, TITUSVILLE, FL 32796 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-02-26 | 123 South Park Avenue, TITUSVILLE, FL 32796 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2014-02-26 | 123 South Park Avenue, TITUSVILLE, FL 32796 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2015-03-24 |
| ANNUAL REPORT | 2014-02-26 |
| ANNUAL REPORT | 2013-01-28 |
| Florida Limited Liability | 2012-10-25 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
