| Name: | Mora Surgical Clinic, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Dissolved |
| Date of registration: | 22 Feb 2001 (24 years ago) |
| Date of dissolution: | 13 Oct 2022 |
| Entity Number: | 000-215-050 |
| Register Number: | 000215050 |
| County: | Autauga |
| Place of Formation: | Autauga County |
| Principal Address: | PRATTVILLE, AL |
| Registered Office Street Address: | 841 GILLESPIE STPRATTVILLE, AL 36067 |
| Registered Office Street Address ZIP Code: | 36067 |
| Authorized Capital: | $1,000 |
| Paid Share Capital: | $1,000 |
Activities
PRACTICE OF MEDICINE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1487794574 | 2007-02-07 | 2020-08-22 | 841 GILLESPIE ST, PRATTVILLE, AL, 360673609, US | 841 GILLESPIE ST, PRATTVILLE, AL, 360673609, US | |||||||||||||||||||||||||||||||
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| Phone | +1 334-361-6126 |
| Fax | 3343616177 |
Authorized person
| Name | MRS. APRIL TILLER |
| Role | OFFICE MANAGER |
| Phone | 3343616126 |
Taxonomy
| Taxonomy Code | 208600000X - Surgery Physician |
| License Number | 20392 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 51501010 |
| State | AL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 51501010 |
| State | AL |
| Name | Role |
|---|---|
| MORA, PARHAM | Agent |
| Name | Role |
|---|---|
| MORA, PARHAM | Incorporator |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
