| Entity Name: | MITCHELL FORMAN, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 17 Mar 2003 (22 years ago) |
| Date of dissolution: | 17 Jan 2014 (11 years ago) |
| Last Event: | VOLUNTARY DISSOLUTION |
| Event Date Filed: | 17 Jan 2014 (11 years ago) |
| Document Number: | P03000032188 |
| FEI/EIN Number | 710937927 |
| Address: | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL, 33544 |
| Mail Address: | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL, 33544 |
| ZIP code: | 33544 |
| County: | Pasco |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1720392558 | 2010-08-04 | 2010-08-04 | 6414 RENWICK CIR, TAMPA, FL, 336471172, US | 1644 BRUCE B DOWNS BLVD, WESLEY CHAPEL, FL, 335448600, US | |||||||||||||||
|
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| Phone | +1 813-929-3600 |
| Fax | 8138668890 |
Authorized person
| Name | MITCHELL FORMAN |
| Role | OWNER |
| Phone | 8139293600 |
Taxonomy
| Taxonomy Code | 261QU0200X - Urgent Care Clinic/Center |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| FORMAN MITCHELL | Agent | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL, 33544 |
| Name | Role | Address |
|---|---|---|
| FORMAN MITCHELL | Director | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL, 33544 |
| Name | Role | Address |
|---|---|---|
| FORMAN PATRICIA | Officer | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL, 33544 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| VOLUNTARY DISSOLUTION | 2014-01-17 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-01-05 | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL 33544 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2011-01-06 | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL 33544 | No data |
| CHANGE OF MAILING ADDRESS | 2011-01-06 | 1644 BRUCE B DOWNS, WESLEY CHAPEL, FL 33544 | No data |
| Document Number | Status | Case Number | Name of Court | Date of Entry | Expiration Date | Amount Due | Plaintiff |
|---|---|---|---|---|---|---|---|
| J11000514245 | TERMINATED | 1000000228497 | HILLSBOROU | 2011-08-05 | 2021-08-10 | $ 965.85 | STATE OF FLORIDA, DEPARTMENT OF REVENUE, TAMPA SERVICE CENTER, 6302 E DR MARTIN LUTHER KING JR BLVD S, TAMPA FL336191166 |
| Name | Date |
|---|---|
| VOLUNTARY DISSOLUTION | 2014-01-17 |
| ANNUAL REPORT | 2013-04-30 |
| ANNUAL REPORT | 2012-01-05 |
| ANNUAL REPORT | 2011-01-06 |
| ANNUAL REPORT | 2010-01-11 |
| ANNUAL REPORT | 2009-01-16 |
| ANNUAL REPORT | 2008-01-16 |
| ANNUAL REPORT | 2007-01-04 |
| ANNUAL REPORT | 2006-01-31 |
| ANNUAL REPORT | 2005-07-01 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
