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East Alabama Family Practice, P.C.

Details

Name: East Alabama Family Practice, P.C.
Jurisdiction: Alabama
Legal type: Domestic Corporation
Status: Exists
Date of registration: 14 May 1996 (29 years ago) (Companies founded in May 1996)
Entity Number: 000-179-637
Register Number: 000179637
ZIP code: 36830 (Companies in Lee, 36830)
County: Lee
Place of Formation: Lee County
Principal Address: AUBURN, AL
Registered Office Street Address: 765B EAST GLENN AVEAUBURN, AL 36830
Authorized Capital: $100
Paid Share Capital: $100

Activities PRACTICE MEDICINE/SALE PHARMACEUTICALS

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1386719193 2006-11-21 2022-12-22 2214 GATEWAY DR, SUITE C, OPELIKA, AL, 368011500, US 2214 GATEWAY DR, SUITE C, OPELIKA, AL, 368011500, US

Contacts
Phone +1 334-741-0075
Fax 3347414075

Authorized person
Name DR. KEITH LYLE FULLER
Role PRESIDENT
Phone 3347410075

Taxonomy
Taxonomy Code 207Q00000X - Family Medicine Physician
License Number DO-350
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 529602340
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2023 631170936 2024-08-26 EAST ALABAMA FAMILY PRACTICE, P.C. 16
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2024-08-23
Name of individual signing KEITH L FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2022 631170936 2023-04-10 EAST ALABAMA FAMILY PRACTICE, P.C. 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2023-04-06
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2023-04-06
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2021 631170936 2022-05-25 EAST ALABAMA FAMILY PRACTICE, P.C. 19
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2022-05-24
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2022-05-24
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2020 631170936 2021-04-23 EAST ALABAMA FAMILY PRACTICE, P.C. 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2021-04-22
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2021-04-22
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2019 631170936 2020-07-10 EAST ALABAMA FAMILY PRACTICE, P.C. 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2020-07-09
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2020-07-09
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2018 631170936 2019-05-01 EAST ALABAMA FAMILY PRACTICE, P.C. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2019-05-01
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2019-05-01
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2017 631170936 2018-09-18 EAST ALABAMA FAMILY PRACTICE, P.C. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2018-09-17
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2018-09-17
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2016 631170936 2017-10-06 EAST ALABAMA FAMILY PRACTICE, P.C. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2017-10-05
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2017-10-05
Name of individual signing KEITH FULLER
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2015 631170936 2016-10-13 EAST ALABAMA FAMILY PRACTICE, P.C. 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2016-10-13
Name of individual signing KEITH FULLER
Role Employer/plan sponsor
Date 2016-10-13
Name of individual signing EAST ALABAMA FAMILY PRACTICE
EAST ALABAMA FAMILY PRACTICE, P.C. 401(K) PLAN 2014 631170936 2015-10-09 EAST ALABAMA FAMILY PRACTICE, P.C. 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 2006-01-01
Business code 621111
Sponsor’s telephone number 3347410075
Plan sponsor’s address 2214 GATEWAY DRIVE, SUITE C, OPELIKA, AL, 36801

Signature of
Role Plan administrator
Date 2015-10-09
Name of individual signing KEITH FULLER

Agent

Name Role Address
ADAMS, DAVID W Agent 1501 MOUNTAIN STREET NEJACKSONVILLE, AL 36265

Incorporator

Name Role
FULLER, KEITH L Incorporator

Related by officers

ADAMS, DAVID W

Victory Fitness, Inc. Struts of Oxford, Inc. Struts of Jacksonville, Inc. Two-Man Land Company, Inc. Struts Event Services, Inc. Jacksonville Entertainment, Inc.

FULLER, KEITH L

Victory Fitness, Inc. Open MRI of Auburn Opelika, L.L.C. New Day, L.L.C. Fuller Properties, Limited Liability Company Beachnut, L.L.C.

Related by address

AUBURN, AL

A-O Rents, Inc. Auburn Electric, Inc. Auburn Leasing, Inc. Auburn-Opelika Real Estate Company, Inc. TeleCable of Lee County, Inc. Beck's Turf-Nursery Inc. Evans Realty, Inc. Bet-Mar, Incorporated Bob-Rita Corporation Camco Vending Corporation

Date of last update: 01 Aug 2024

Sources: Alabama Secretary of State

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