| Entity Name: | JACK L. CASSELL, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Profit Corporation |
| Status: | Active |
| Date Filed: | 10 Jan 1990 (35 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 30 Jan 2024 (a year ago) |
| Document Number: | L42625 |
| FEI/EIN Number | 59-2986872 |
| Address: | 717 N. DONNELLY ST., MOUNT DORA, FL 32757 |
| Mail Address: | 717 N. DONNELLY ST., MOUNT DORA, FL 32757 |
| ZIP code: | 32757 |
| County: | Lake |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366630808 | 2007-10-10 | 2010-12-08 | 717 N DONNELLY ST, MOUNT DORA, FL, 327574833, US | 717 N DONNELLY ST, MOUNT DORA, FL, 327574833, US | |||||||||||||||||||||||||
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| Phone | +1 352-383-3773 |
| Fax | 3523834434 |
Authorized person
| Name | JACK L CASSELL |
| Role | OWNER/PHYSICAN |
| Phone | 3523833773 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME46095 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 254899200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Campione, Leslie | Agent | 342 E 5TH AVE, MOUNT DORA, FL 32757 |
| Name | Role | Address |
|---|---|---|
| CASSELL, JACK L | President | 717 N. DONNELLY ST., MOUNT DORA, FL 32757 |
| CAMPIONE, LESLIE | President | 342 E 5TH AVE, MOUNT DORA, FL 32757 |
| Name | Role | Address |
|---|---|---|
| CASSELL, JACK L | Director | 717 N. DONNELLY ST., MOUNT DORA, FL 32757 |
| CAMPIONE, LESLIE | Director | 342 E 5TH AVE, MOUNT DORA, FL 32757 |
| Name | Role | Address |
|---|---|---|
| CAMPIONE, LESLIE | Vice President | 342 E 5TH AVE, MOUNT DORA, FL 32757 |
| Name | Role | Address |
|---|---|---|
| CAMPIONE, LESLIE | Secretary | 342 E 5TH AVE, MOUNT DORA, FL 32757 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000066329 | DR. TATZAP | EXPIRED | 2016-07-06 | 2021-12-31 | No data | 717 N. DONNELLY ST., MOUNT DORA, FL, 32757 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2024-01-30 | No data | No data |
| REINSTATEMENT | 2020-04-13 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2020-04-13 | 342 E 5TH AVE, MOUNT DORA, FL 32757 | No data |
| REGISTERED AGENT NAME CHANGED | 2020-04-13 | Campione, Leslie | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| CANCEL ADM DISS/REV | 2005-10-06 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
| CANCEL ADM DISS/REV | 2004-10-21 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2004-10-01 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2003-04-07 | 717 N. DONNELLY ST., MOUNT DORA, FL 32757 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-08 |
| Amendment | 2024-01-30 |
| ANNUAL REPORT | 2023-01-30 |
| ANNUAL REPORT | 2022-01-26 |
| ANNUAL REPORT | 2021-02-04 |
| REINSTATEMENT | 2020-04-13 |
| ANNUAL REPORT | 2018-03-02 |
| ANNUAL REPORT | 2017-07-06 |
| ANNUAL REPORT | 2016-01-23 |
| ANNUAL REPORT | 2015-01-09 |
Date of last update: 03 Feb 2025
Sources: Florida Department of State
