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) (Companies founded in April 2012) |
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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
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 | |||||||||||||||||||||||||||||||
|
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