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  5. ADULT MEDICINE OF LAKE COUNTY, INC.

ADULT MEDICINE OF LAKE COUNTY, INC.

Company Details

Entity Name: ADULT MEDICINE OF LAKE COUNTY, INC.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Active
Date Filed: 15 Dec 1997 (27 years ago)
Last Event: REINSTATEMENT
Event Date Filed: 29 Oct 2019 (5 years ago)
Document Number: P97000105435
FEI/EIN Number 593483343
Address: 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757
Mail Address: 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757
ZIP code: 32757
County: Lake
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1851450209 2006-12-08 2024-11-04 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364, US 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364, US

Contacts
Phone +1 352-383-8222
Fax 3523831420

Authorized person
Name SHIRLEY NAGEL
Role PRESIDENT
Phone 3523838222

Taxonomy
Taxonomy Code 207R00000X - Internal Medicine Physician
Is Primary Yes

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
ADULT MEDICINE OF LAKE COUNTY 401(K) PROFIT SHARING PLAN AND TRUST 2023 593483343 2024-08-08 ADULT MEDICINE OF LAKE COUNTY INC. 59
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523838222
Plan sponsor’s address 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

Signature of
Role Plan administrator
Date 2024-08-08
Name of individual signing MARILYN DOYLE
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401(K) PROFIT SHARING PLAN AND TRUST 2022 593483343 2023-09-29 ADULT MEDICINE OF LAKE COUNTY INC. 47
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2019-01-01
Business code 621111
Sponsor’s telephone number 3523838222
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Signature of
Role Plan administrator
Date 2023-09-29
Name of individual signing MARILYN DOYLE
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2014 593483343 2015-07-31 ADULT MEDICINE OF LAKE COUNTY 24
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Signature of
Role Plan administrator
Date 2015-07-31
Name of individual signing ANN PIKE
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2014 593483343 2015-07-31 ADULT MEDICINE OF LAKE COUNTY 25
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Signature of
Role Plan administrator
Date 2015-07-31
Name of individual signing ANN PIKE
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2013 593483343 2014-06-20 ADULT MEDICINE OF LAKE COUNTY 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Signature of
Role Plan administrator
Date 2014-06-20
Name of individual signing ANN M PIKE
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2012 593483343 2013-06-20 ADULT MEDICINE OF LAKE COUNTY 20
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Signature of
Role Plan administrator
Date 2013-06-20
Name of individual signing ADULT MEDICINE OF LAKE COUNTY
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2011 593483343 2012-10-04 ADULT MEDICINE OF LAKE COUNTY 23
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364

Plan administrator’s name and address
Administrator’s EIN 593483343
Plan administrator’s name ADULT MEDICINE OF LAKE COUNTY
Plan administrator’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 327572364
Administrator’s telephone number 3523839057

Signature of
Role Plan administrator
Date 2012-10-04
Name of individual signing ADULT MEDICINE OF LAKE COUNTY
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 401 K PROFIT SHARING PLAN TRUST 2010 593483343 2012-10-04 ADULT MEDICINE OF LAKE COUNTY 23
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757

Plan administrator’s name and address
Administrator’s EIN 593483343
Plan administrator’s name ADULT MEDICINE OF LAKE COUNTY
Plan administrator’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757
Administrator’s telephone number 3523839057

Signature of
Role Plan administrator
Date 2012-10-04
Name of individual signing ADULT MEDICINE OF LAKE COUNTY
Valid signature Filed with authorized/valid electronic signature
ADULT MEDICINE OF LAKE COUNTY 2009 593483343 2010-08-02 ADULT MEDICINE OF LAKE COUNTY 21
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757

Plan administrator’s name and address
Administrator’s EIN 593483343
Plan administrator’s name ADULT MEDICINE OF LAKE COUNTY
Plan administrator’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757
Administrator’s telephone number 3523839057

Signature of
Role Plan administrator
Date 2010-08-02
Name of individual signing ADULT MEDICINE OF LAKE COUNTY
Valid signature Filed with incorrect/unrecognized electronic signature
ADULT MEDICINE OF LAKE COUNTY 2009 593483343 2010-08-03 ADULT MEDICINE OF LAKE COUNTY 21
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2000-01-01
Business code 621111
Sponsor’s telephone number 3523839057
Plan sponsor’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757

Plan administrator’s name and address
Administrator’s EIN 593483343
Plan administrator’s name ADULT MEDICINE OF LAKE COUNTY
Plan administrator’s address 3619 LAKE CENTER DR, MOUNT DORA, FL, 32757
Administrator’s telephone number 3523839057

Signature of
Role Plan administrator
Date 2010-08-03
Name of individual signing ADULT MEDICINE OF LAKE COUNTY
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
NAGEL SHIRLEY M Agent 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

Director

Name Role Address
NAGEL SHIRLEY M Director 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757
DAVINA ELEANOR Director 3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

Fictitious Names

Registration Number Fictitious Name Status Filed Date Expiration Date Cancellation Date Mailing Address
G20000092831 MED SPA MOUNT DORA ACTIVE 2020-07-31 2025-12-31 No data 3587 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

Events

Event Type Filed Date Value Description
REINSTATEMENT 2019-10-29 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2019-09-27 No data No data
REGISTERED AGENT NAME CHANGED 2018-10-31 NAGEL, SHIRLEY MD No data
REINSTATEMENT 2018-10-31 No data No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2018-09-28 No data No data
REGISTERED AGENT ADDRESS CHANGED 2008-01-15 3619 LAKE CENTER DRIVE, MOUNT DORA, FL 32757 No data
CHANGE OF PRINCIPAL ADDRESS 2008-01-15 3619 LAKE CENTER DRIVE, MOUNT DORA, FL 32757 No data
CHANGE OF MAILING ADDRESS 2008-01-15 3619 LAKE CENTER DRIVE, MOUNT DORA, FL 32757 No data

Debts

Document Number Status Case Number Name of Court Date of Entry Expiration Date Amount Due Plaintiff
J22000027005 ACTIVE 35-2021-CA-001989-AXXX-XX CIRCUIT COURT, LAKE COUNTY 2021-10-15 2027-01-18 $168,974.29 BALBOA CAPITAL CORPORATION, 575 ANTON BLVD, 12TH FLOOR, COSTA MESA, CA 92626

Documents

Name Date
ANNUAL REPORT 2025-01-22
ANNUAL REPORT 2024-02-09
ANNUAL REPORT 2023-02-24
ANNUAL REPORT 2022-01-26
ANNUAL REPORT 2021-05-19
ANNUAL REPORT 2020-06-12
REINSTATEMENT 2019-10-29
REINSTATEMENT 2018-10-31
ANNUAL REPORT 2017-02-13
ANNUAL REPORT 2016-03-03

Related by officers

DAVINA ELEANOR

MEDSPA OF MOUNT DORA INC. CLINICAL RESEARCH OF ADULT MEDICINE LLC KALEIDOSCOPE MARKETING CONCEPTS, LLC WELLCARE PROPERTIES, L.L.C.

Related by address

3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

MOUNT DORA CENTER FOR WELLNESS AND VITALITY, INC. BODY BY US LLC CLINICAL RESEARCH OF ADULT MEDICINE LLC KALEIDOSCOPE MARKETING CONCEPTS, LLC

3619 LAKE CENTER DRIVE, MOUNT DORA, FL, 32757

MOUNT DORA CENTER FOR WELLNESS AND VITALITY, INC. BODY BY US LLC CLINICAL RESEARCH OF ADULT MEDICINE LLC KALEIDOSCOPE MARKETING CONCEPTS, LLC

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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