| Name: | Fort Payne Pediatrics, L.L.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 05 Apr 2012 (13 years ago) |
| Entity Number: | 000-049-602 |
| Register Number: | 000049602 |
| Place of Formation: | DeKalb County |
| Principal Address: | 1359 OLD WATERWORKS RD SWFORT PAYNE, AL 35968-3347 |
Activities
PROVIDE PEDIATRIC AND OTHER HEALTH CARE SERVICES
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| J2USMHKEKY23 | 2023-07-15 | 1359 OLD WATER WORKS RD SW, FORT PAYNE, AL, 35968, 3347, USA | 1359 OLD WATER WORKS RD SW, FORT PAYNE, AL, 35968, 3347, USA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| URL | http://fortpaynepeds.com/ |
| Congressional District | 04 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2022-07-19 |
| Initial Registration Date | 2012-07-15 |
| Entity Start Date | 2012-05-09 |
| Fiscal Year End Close Date | Dec 31 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | CHARLES ROSE |
| Role | CFO |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, 3347, USA |
| Title | ALTERNATE POC |
| Name | MORGAN PINHOLSTER |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, 3546, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | CHARLES ROSE |
| Role | CFO |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, 3347, USA |
| Title | ALTERNATE POC |
| Name | MORGAN PINHOLSTER |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, 3546, USA |
| Past Performance | |
|---|---|
| Title | PRIMARY POC |
| Name | MORGAN PINHOLSTER |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, USA |
| Title | ALTERNATE POC |
| Name | CHARLES ROSE |
| Role | CFO |
| Address | 1359 OLD WATERWORKS RD SW, FORT PAYNE, AL, 35968, USA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1356746085 | 2014-10-23 | 2023-08-08 | 1359 OLD WATER WORKS RD SW, FORT PAYNE, AL, 359683347, US | 1359 OLD WATER WORKS RD SW, FORT PAYNE, AL, 359683347, US | |||||||||||||||||||||||||||||||
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| Phone | +1 256-997-5900 |
| Fax | 2569975995 |
Authorized person
| Name | DR. PETER STROGOV |
| Role | PRESIDENT |
| Phone | 2569975900 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | No |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 177834 |
| State | AL |
| Issuer | MEDICAID |
| Number | 167395 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| STROGOV, PETER | Agent | 1359 OLD WATERWORKS ROAD SOUTHWESTFORT PAYNE, AL 35968 |
| Name | Role | Address |
|---|---|---|
| STROGOV, PETER | Organizer | 1359 OLD WATERWORKS ROAD SOUTHWESTFORT PAYNE, AL 35968 |
Date of last update: 30 Jul 2024
Sources: Alabama Secretary of State
