| Entity Name: | TAMPA INSTITUTE FOR PAIN AND SPINE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Inactive |
| Date Filed: | 19 May 2016 (9 years ago) |
| Date of dissolution: | 25 Sep 2020 (4 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 25 Sep 2020 (4 years ago) |
| Document Number: | L16000098353 |
| FEI/EIN Number | 81-2746471 |
| Address: | 4303 Church Pond Pl, Dover, FL, 33527, US |
| Mail Address: | 3403 Church pond pl, Dover, FL, 33527, US |
| ZIP code: | 33527 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1134571128 | 2016-07-01 | 2018-07-31 | 13140 ELK MOUNTAIN DR, SUITE B, RIVERVIEW, FL, 335797182, US | 13140 ELK MOUNTAIN DR, SUITE B, RIVERVIEW, FL, 33579, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 813-513-8477 |
Authorized person
| Name | JESSEN MUKALEL |
| Role | PRESIDENT |
| Phone | 8135138477 |
Taxonomy
| Taxonomy Code | 207LP2900X - Pain Medicine (Anesthesiology) Physician |
| Is Primary | No |
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0000X - Pain Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 208VP0014X - Interventional Pain Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 18353700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MUKALEL JESSEN J | Agent | 4303 Church pond pl, Dover, FL, 33527 |
| Name | Role | Address |
|---|---|---|
| MUKALEL JESSEN J | Manager | 4303 Church Pond Pl, Dover, FL, 33527 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2020-09-25 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2019-02-12 | 4303 Church Pond Pl, Dover, FL 33527 | No data |
| CHANGE OF MAILING ADDRESS | 2019-02-12 | 4303 Church Pond Pl, Dover, FL 33527 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2019-02-12 | 4303 Church pond pl, Dover, FL 33527 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2019-02-12 |
| ANNUAL REPORT | 2018-04-08 |
| ANNUAL REPORT | 2017-02-21 |
| Florida Limited Liability | 2016-05-19 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
