| Name: | Good Samaritan Hospice USA, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Dissolved |
| Date of registration: | 15 Jul 2003 (21 years ago) |
| Date of dissolution: | 02 Sep 2020 |
| Entity Number: | 000-230-019 |
| Register Number: | 000230019 |
| County: | Colbert |
| Place of Formation: | Colbert County |
| Principal Address: | MUSCLE SHOALS, AL |
| Registered Office Street Address: | 701 DAVIDSON AVEMUSCLE SHOALS, AL 35661 |
| Registered Office Street Address ZIP Code: | 35661 |
| Authorized Capital: | $18 |
Activities
PROVIDE HOSPICE SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1396767224 | 2006-07-23 | 2008-06-26 | 402 E DR HICKS BLVD, FLORENCE, AL, 356305763, US | 402 E DR HICKS BLVD, FLORENCE, AL, 356305763, US | |||||||||||||||||||||||||||||||
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| Phone | +1 256-767-4799 |
| Fax | 2567674798 |
Authorized person
| Name | MR. JACKIE RANDOLPH GIST |
| Role | PRESIDENT |
| Phone | 2567674799 |
Taxonomy
| Taxonomy Code | 251G00000X - Community Based Hospice Care Agency |
| License Number | 12948 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | PIC1595E |
| State | AL |
| Issuer | BLUE CROSS ALABAMA |
| Number | 01200654 |
| State | AL |
| Name | Role |
|---|---|
| BOORGU, RAJESH | Agent |
| Name | Role | Address |
|---|---|---|
| ECKL, CAROL L | Incorporator | 401 E TUSCALOOSA STREETFLORENCE, AL 35630 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
