| Entity Name: | FL PSYCHIATRIC SERVICES LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 26 Aug 2020 (4 years ago) |
| Document Number: | L20000266102 |
| FEI/EIN Number | 85-2893839 |
| Mail Address: | 1 SE Ocean Blvd, Stuart, FL 34994 |
| Address: | 4203 NE Skyline Dr, Jensen Beach, FL 34957 |
| ZIP code: | 34957 |
| County: | Martin |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1497354690 | 2020-10-20 | 2021-07-27 | PO BOX 3743, YOUNGSTOWN, OH, 445133743, US | 1 SE OCEAN BLVD, STUART, FL, 349942214, US | |||||||||||||||||||||||||||||
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| Phone | +1 330-965-9999 |
| Fax | 3307570000 |
| Phone | +1 772-400-2875 |
| Fax | 7724002876 |
Authorized person
| Name | MUHANNAD KASSAWAT |
| Role | OWNER |
| Phone | 3309659999 |
Taxonomy
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | PENDING |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KASSAWAT, MUHANNAD | Agent | 4203 NE Skyline Dr, Jensen Beach, FL 34957 |
| Name | Role | Address |
|---|---|---|
| KASSAWAT, MUHANNAD | Chief Executive Officer | 4203 NE Skyline Dr, Jensen Beach, FL 34957 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2021-02-09 | 4203 NE Skyline Dr, Jensen Beach, FL 34957 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2021-02-09 | 4203 NE Skyline Dr, Jensen Beach, FL 34957 | No data |
| CHANGE OF MAILING ADDRESS | 2020-11-25 | 4203 NE Skyline Dr, Jensen Beach, FL 34957 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-25 |
| ANNUAL REPORT | 2023-05-01 |
| ANNUAL REPORT | 2022-05-31 |
| ANNUAL REPORT | 2021-02-09 |
| Florida Limited Liability | 2020-08-26 |
Date of last update: 14 Feb 2025
Sources: Florida Department of State
