| Name: | Dothan Pediatric Clinic, P.A. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Association |
| Status: | Exists |
| Date of registration: | 25 Nov 1985 (39 years ago) |
| Entity Number: | 000-006-086 |
| Register Number: | 000006086 |
| County: | Houston |
| Place of Formation: | Houston County |
| Principal Address: | 2020 ALEXANDER DRIVEDOTHAN, AL 36301 |
| Principal Address ZIP Code: | 36301 |
| Registered Office Street Address: | 126 CLINIC DRIVEDOTHAN, AL 36303 |
| Registered Office Street Address ZIP Code: | 36303 |
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MXE5TEWK6LW1 | 2024-09-27 | 126 CLINIC DR, DOTHAN, AL, 36303, 1980, USA | 126 CLINIC DR, DOTHAN, AL, 36303, 1980, USA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Congressional District | 02 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2023-09-29 |
| Initial Registration Date | 2010-12-02 |
| Entity Start Date | 1953-01-01 |
| Fiscal Year End Close Date | Dec 31 |
Service Classifications
| NAICS Codes | 621111 |
| Product and Service Codes | Q999 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | PRUDENCE NELSON |
| Address | DOTHAN PEDIATRIC CLINIC, 126 CLINIC DRIVE, DOTHAN, AL, 36303, 1980, USA |
| Title | ALTERNATE POC |
| Name | BRANDY FLUCKER |
| Address | DOTHAN PEDIATRIC CLINIC, 126 CLINIC DRIVE, DOTHAN, AL, 36303, 1980, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | PRUDENCE NELSON |
| Address | DOTHAN PEDIATRIC CLINIC, 126 CLINIC DRIVE, DOTHAN, AL, 36303, 1980, USA |
| Title | ALTERNATE POC |
| Name | BRANDY FLUCKER |
| Address | DOTHAN PEDIATRIC CLINIC, 126 CLINIC DRIVE, DOTHAN, AL, 36303, 1980, USA |
| Past Performance | |
|---|---|
| Title | ALTERNATE POC |
| Name | GINA TOLAR |
| Address | 126 CLINIC DR., DOTHAN, AL, 36303, USA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457027955 | 2021-08-17 | 2021-08-17 | 126 CLINIC DR, DOTHAN, AL, 363031980, US | 5565 MONTGOMERY HWY, DOTHAN, AL, 363031552, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 334-793-1881 |
| Phone | +1 334-699-3733 |
Authorized person
| Name | GINA TOLAR |
| Role | INSURANCE & COLLECTION SUPERVISOR |
| Phone | 3347931881 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | Yes |
| Taxonomy Code | 2080P0205X - Pediatric Endocrinology Physician |
| Is Primary | No |
| Taxonomy Code | 2080P0206X - Pediatric Gastroenterology Physician |
| Is Primary | No |
| Taxonomy Code | 2080P0214X - Pediatric Pulmonology Physician |
| Is Primary | No |
| Taxonomy Code | 2080S0012X - Pediatric Sleep Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 2084N0402X - Neurology with Special Qualifications in Child Neurology Physician |
| Is Primary | No |
| Taxonomy Code | 363LP0200X - Pediatric Nurse Practitioner |
| Is Primary | No |
| CAGE number | Status | Type | Established | CAGE Update Date | CAGE Expiration | SAM Expiration | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 67BN4 | Active | Non-Manufacturer | 2010-12-02 | 2024-08-15 | 2029-08-15 | 2025-08-13 | |||||||||||||||
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| POC | PRUDENCE NELSON |
| Phone | +1 334-793-1881 |
| Fax | +1 334-340-5918 |
| Address | 126 CLINIC DR, DOTHAN, AL, 36303 1980, UNITED STATES |
Ownership of Offeror Information
| Highest Level Owner | Information not Available |
|---|
| Immediate Level Owner | Information not Available |
|---|
| List of Offerors (0) | Information not Available |
|---|
| Name | Role |
|---|---|
| ROBERT J BENAK | Agent |
| Name | Role | Address |
|---|---|---|
| BARRON, WILLIAM R | Member | No data |
| LIES, WILLIAM III | Member | No data |
| DRIGGERS, ROY M | Member | No data |
| BENAK, ROBERT J | Member | No data |
| WILEY, JAMES C | Member | 3930-F AIRPORT BLVDMOBILE, AL 36608 |
Date of last update: 30 Jul 2024
Sources: Alabama Secretary of State
