| Name: | MedPeds of Dothan, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Dissolved |
| Date of registration: | 12 Jan 2004 (21 years ago) (Companies founded in January 2004) |
| Date of dissolution: | 02 Dec 2019 |
| Entity Number: | 000-232-999 |
| Register Number: | 000232999 |
| ZIP code: | 36303 (Companies in Houston, 36303) |
| County: | Houston |
| Place of Formation: | Houston County |
| Principal Address: | DOTHAN, AL |
| Registered Office Street Address: | 318 WESTGATE PKWY STE 2DOTHAN, AL 36303 |
| Authorized Capital: | 100 NPV |
Activities
OWN/CONTROL/OPERATE A PHYSICIAN'S BUSINESS
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1427252766 | 2007-06-12 | 2007-07-16 | 318 WESTGATE PARKWAY STE 2, DOTHAN, AL, 36303, US | 318 WESTGATE PKWY STE 2, DOTHAN, AL, 363032963, US | |||||||||||||||||||||||||||||||||
|
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| Phone | +1 334-671-2895 |
| Fax | 3347129430 |
Authorized person
| Name | KRISTIN BOUTWELL |
| Role | ADMINISTRATION |
| Phone | 3346712895 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | 00024928 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 2080A0000X - Pediatric Adolescent Medicine Physician |
| License Number | 00024928 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 009946055 |
| State | AL |
| Name | Role |
|---|---|
| MASTERS, FIONA I | Agent |
| Name | Role |
|---|---|
| MASTERS, FIONA I | Incorporator |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
