| Entity Name: | BRAIN SPINE AND SLEEP INSTITUTE LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 19 Jul 2016 (9 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 17 Apr 2024 (10 months ago) |
| Document Number: | L16000135728 |
| FEI/EIN Number | 81-3319008 |
| Address: | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 |
| Mail Address: | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 |
| ZIP code: | 33853 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386190734 | 2016-08-26 | 2023-03-07 | 1120 CARLTON AVE, SUITE 1300, LAKE WALES, FL, 338534347, US | 1120 CARLTON AVE, SUITE 1300, LAKE WALES, FL, 338534347, US | |||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||
| Phone | +1 863-676-6386 |
| Fax | 8636763124 |
Authorized person
| Name | HASAN M MOUSLI |
| Role | OWNER/MD |
| Phone | 8636766386 |
Taxonomy
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | Yes |
| Taxonomy Code | 2084P2900X - Pain Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
| Taxonomy Code | 2084S0012X - Sleep Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | LICENSE |
| Number | ME97722 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BRAIN SPINE AND SLEEP INSTITUTE 401(K) PLAN | 2023 | 813319008 | 2024-05-23 | BRAIN SPINE AND SLEEP INSTITUTE | 3 | |||||||||||||||||||||||
|
||||||||||||||||||||||||||||
| Role | Plan administrator |
| Date | 2024-05-23 |
| Name of individual signing | DESTINY BARGER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-05-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 8634091362 |
| Plan sponsor’s address | 1120 CARLTON AVE. STE 1300, LAKE WALES, FL, 33853 |
Signature of
| Role | Plan administrator |
| Date | 2023-05-30 |
| Name of individual signing | DESTINY BARGER |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-05-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 8634091362 |
| Plan sponsor’s address | 1120 CARLTON AVE. STE 1300, LAKE WALES, FL, 33853 |
Signature of
| Role | Plan administrator |
| Date | 2022-05-26 |
| Name of individual signing | MILCAH CACULITAN |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-05-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 8634091362 |
| Plan sponsor’s address | 1120 CARLTON AVE. STE 1300, LAKE WALES, FL, 33853 |
Signature of
| Role | Plan administrator |
| Date | 2022-04-07 |
| Name of individual signing | MILCAH CACULITAN |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2019-05-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 8634091362 |
| Plan sponsor’s address | 1120 CARLTON AVE. SUITE 1300, LAKE WALES, FL, 33853 |
Signature of
| Role | Plan administrator |
| Date | 2020-10-15 |
| Name of individual signing | MILCAH CACULITAN |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| MOUSLI, HASAN M, Dr. | Agent | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 |
| Name | Role | Address |
|---|---|---|
| MOUSLI, HASAN | Manager | 1120 Carlton Ave, Suite 1300 WINTER HAVEN, FL 33853 |
| Abbas, Zeena | Manager | 1120 Carlton Ave, Suite 1300 WINTER HAVEN, FL 33853 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REINSTATEMENT | 2024-04-17 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2024-04-17 | MOUSLI, HASAN M, Dr. | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2023-09-22 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-06-30 | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 | No data |
| CHANGE OF MAILING ADDRESS | 2020-06-30 | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-06-30 | 1120 Carlton Ave, Suite 1300, WINTER HAVEN, FL 33853 | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2024-04-17 |
| ANNUAL REPORT | 2022-05-01 |
| ANNUAL REPORT | 2021-05-01 |
| ANNUAL REPORT | 2020-06-30 |
| ANNUAL REPORT | 2019-04-27 |
| ANNUAL REPORT | 2018-01-23 |
| ANNUAL REPORT | 2017-04-04 |
| Florida Limited Liability | 2016-07-19 |
Date of last update: 19 Jan 2025
Sources: Florida Department of State
