| Name: | Andalusia Greater Regional Otolaryngology-ENT, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 18 Apr 2003 (22 years ago) |
| Entity Number: | 000-228-646 |
| Register Number: | 000228646 |
| County: | Covington |
| Place of Formation: | Covington County |
| Registered Office Street Address: | 300 MEDICAL AVE STE 2ANDALUSIA, AL 36420 |
| Registered Office Street Address ZIP Code: | 36420 |
| Authorized Capital: | $2,000 |
Activities
MEDICINE PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1548438815 | 2008-02-20 | 2016-12-19 | 300 MEDICAL AVENUE, 2, ANDALUSIA, AL, 364201201, US | 300 MEDICAL AVENUE, 2, ANDALUSIA, AL, 364201201, US | |||||||||||||||||||||||||
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| Phone | +1 334-427-2476 |
| Fax | 3344272477 |
Authorized person
| Name | DR. RICKEY G LOVE |
| Role | DOCTOR/PRESIDENT |
| Phone | 3344272476 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 12982 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 529914990 |
| State | AL |
| Name | Role |
|---|---|
| LOVE, R G | Agent |
| Name | Role | Address |
|---|---|---|
| ALBRITTON, THOMAS B | Incorporator | 109 OPP AVENUEANDALUSIA, AL 36420 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
