| Name: | Dothan Behavioral Medicine Clinic, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 17 Jan 2001 (24 years ago) |
| Entity Number: | 000-214-230 |
| Register Number: | 000214230 |
| County: | Houston |
| Place of Formation: | Houston County |
| Principal Address: | DOTHAN, AL |
| Registered Office Street Address: | 101 MEDICAL DRDOTHAN, AL 36305 |
| Registered Office Street Address ZIP Code: | 36305 |
| Authorized Capital: | $1,200 |
Activities
MEDICAL PRACTICE OF PSYCHOLOGY/PSYCHIATRY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1295166346 | 2013-11-27 | 2017-01-18 | 408 HEALTHWEST DR, DOTHAN, AL, 363032054, US | 408 HEALTHWEST DR, DOTHAN, AL, 363032054, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 334-479-0541 |
| Fax | 3344790586 |
Authorized person
| Name | SUSANNAH DAUGHTRY |
| Role | DIRECTOR OF PHARMACY |
| Phone | 3347961548 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | 114222 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PK |
| Number | 2143097 |
| Issuer | MEDICAID |
| Number | 154463 |
| State | AL |
| Name | Role |
|---|---|
| HANDAL, NELSON | Incorporator |
| Name | Role |
|---|---|
| HANDAL, NELSON | Agent |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
