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Lisenby Podiatry, P.C.

Details

Name: Lisenby Podiatry, P.C.
Jurisdiction: Alabama
Legal type: Domestic Professional Corporation
Status: Dissolved
Date of registration: 08 Feb 1995 (30 years ago) (Companies founded in February 1995)
Date of dissolution: 14 Mar 2017
Entity Number: 000-169-940
Register Number: 000169940
ZIP code: 36303 (Companies in Houston, 36303)
County: Houston
Place of Formation: Houston County
Principal Address: DOTHAN, AL
Registered Office Street Address: 1085 ROSS CLARK CIRCLE STE CDOTHAN, AL 36303
Authorized Capital: $1,000
Paid Share Capital: $1,000

Activities PROFESSION OF PODIATRY

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1104990415 2006-11-20 2009-05-26 1550 E MAIN ST, DOTHAN, AL, 363013012, US 1550 E MAIN ST, DOTHAN, AL, 363013012, US

Contacts
Phone +1 334-671-1441
Fax 3346711688

Authorized person
Name DR. ROBERT HARRISON LISENBY JR.
Role PRESIDENT
Phone 3346711441

Taxonomy
Taxonomy Code 213E00000X - Podiatrist
License Number 144
State AL
Is Primary Yes
Taxonomy Code 213E00000X - Podiatrist
License Number 511
State GA
Is Primary No

Other Provider Identifiers
Issuer MEDICAID
Number 000074869
State AL
Issuer BCBS
Number 74869
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2016 631165685 2017-10-16 LISENBY PODIATRY, P.C. 1
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2015 631165685 2016-08-04 LISENBY PODIATRY, P.C. 1
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2014 631165685 2016-08-04 LISENBY PODIATRY, P.C. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2014 631165685 2015-10-15 LISENBY PODIATRY, P.C. 4
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441

Signature of
Role Plan administrator
Date 2015-10-15
Name of individual signing PAULA L. SHELLEY
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2013 631165685 2016-08-04 LISENBY PODIATRY, P.C. 5
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2013 631165685 2014-10-14 LISENBY PODIATRY, P.C. 4
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441

Signature of
Role Plan administrator
Date 2014-10-14
Name of individual signing ROBERT H. LISENBY, JR.
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2012 631165685 2013-10-15 LISENBY PODIATRY, P.C. 4
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441

Signature of
Role Plan administrator
Date 2013-10-15
Name of individual signing ROBERT H. LISENBY, JR.
LISENBY PODIATRY, P.C. PROFIT SHARING PLAN 2011 631165685 2012-10-12 LISENBY PODIATRY, P.C. 3
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621391
Sponsor’s telephone number 3346711441
Plan sponsor’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301

Plan administrator’s name and address
Administrator’s EIN 631165685
Plan administrator’s name LISENBY PODIATRY, P.C.
Plan administrator’s address 1550 EAST MAIN STREET, DOTHAN, AL, 36301
Administrator’s telephone number 3346711441

Signature of
Role Plan administrator
Date 2012-10-12
Name of individual signing ROBERT H. LISENBY, JR.

Agent

Name Role
LISENBY, ROBERT H JR Agent

Incorporator

Name Role
LISENBY, ROBERT H JR Incorporator

Related by officers

No related officers

Related by address

DOTHAN, AL

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Date of last update: 01 Aug 2024

Sources: Alabama Secretary of State

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