Hatley Health Care, Inc.

Contacts

Phone	+1 205-755-4960
Fax	2057552455

Authorized person

Name	MRS. RICHIE SCOGGINS
Role	ADMINISTRATOR
Phone	2057554960

Taxonomy

Taxonomy Code	314000000X - Skilled Nursing Facility
License Number	12497
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	BLUE CROSS PROVIDER NO
Number	010523
State	AL
Issuer	MEDICAID
Number	4757430S
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1992-01-01
Business code	623000
Sponsor’s telephone number	2057554960
Plan sponsor’s address	300 MEDICAL CENTER DR., CLANTON, AL, 35045

Signature of

Role	Plan administrator
Date	2024-08-05
Name of individual signing	LANCE BOLDING

File	View Page
Three-digit plan number (PN)	502
Effective date of plan	2021-07-01
Business code	623000
Sponsor’s telephone number	2052584001
Plan sponsor’s mailing address	300 MEDICAL CENTER DR, CLANTON, AL, 350452321
Plan sponsor’s address	300 MEDICAL CENTER DR, CLANTON, AL, 350452321

Number of participants as of the end of the plan year

Retired or separated participants receiving benefits	0
Other retired or separated participants entitled to future benefits	0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0
Number of participants with account balances as of the end of the plan year	0
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	0

Signature of

Role	Plan administrator
Date	2023-03-08
Name of individual signing	LANCE BOLDING
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2023-03-08
Name of individual signing	LANCE BOLDING
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	502
Effective date of plan	2019-07-01
Business code	623000
Sponsor’s telephone number	2057554960
Plan sponsor’s mailing address	300 MEDICAL CENTER DR, CLANTON, AL, 350452321
Plan sponsor’s address	300 MEDICAL CENTER DR, CLANTON, AL, 350452321

Number of participants as of the end of the plan year

Active participants

136

Signature of

Role	Plan administrator
Date	2020-09-09
Name of individual signing	LANCE BOLDING
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2020-09-09
Name of individual signing	LANCE BOLDING
Valid signature	Filed with authorized/valid electronic signature