| Entity Name: | BRAIN AND SPINE INSTITUTE OF PORT ORANGE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 05 Mar 2013 (12 years ago) |
| Last Event: | LC AMENDMENT |
| Event Date Filed: | 23 Sep 2015 (9 years ago) |
| Document Number: | L13000033635 |
| FEI/EIN Number | 46-2188890 |
| Address: | 1211 Dunlawton Avenue, PORT ORANGE, FL, 32127, US |
| Mail Address: | 1211 Dunlawton Avenue, PORT ORANGE, FL, 32127, US |
| ZIP code: | 32127 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1699016949 | 2013-03-12 | 2013-03-15 | 1211 DUNLAWTON AVE, PORT ORANGE, FL, 321272913, US | 1211 DUNLAWTON AVE, PORT ORANGE, FL, 321272913, US | |||||||||||||||||||||||||||||
|
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| Phone | +1 386-304-0111 |
Authorized person
| Name | DR. TIMOTHY JOSEPH WIERZBICKI |
| Role | CEO |
| Phone | 3863040111 |
Taxonomy
| Taxonomy Code | 2084N0400X - Neurology Physician |
| License Number | ME80334 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 259058100 |
| State | FL |
| Issuer | MEDICARE RAILROAD |
| Number | 130022355 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| WIERZBICKI TIMOTHY J | Agent | 1211 Dunlawton Avenue, PORT ORANGE, FL, 32127 |
| Name | Role | Address |
|---|---|---|
| WIERZBICKI TIMOTHY J | Managing Member | 1211 Dunlawton Avenue, PORT ORANGE, FL, 32127 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| LC AMENDMENT | 2015-09-23 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-04-29 | 1211 Dunlawton Avenue, PORT ORANGE, FL 32127 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2014-01-18 | 1211 Dunlawton Avenue, PORT ORANGE, FL 32127 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-18 | 1211 Dunlawton Avenue, PORT ORANGE, FL 32127 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-05 |
| ANNUAL REPORT | 2023-01-20 |
| ANNUAL REPORT | 2022-03-14 |
| ANNUAL REPORT | 2021-02-24 |
| ANNUAL REPORT | 2020-06-15 |
| ANNUAL REPORT | 2019-04-25 |
| ANNUAL REPORT | 2018-04-24 |
| ANNUAL REPORT | 2017-01-13 |
| ANNUAL REPORT | 2016-01-15 |
| LC Amendment | 2015-09-23 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
