Wiregrass Family Practice of Dothan, P.C.

Details

Name:	Wiregrass Family Practice of Dothan, P.C.
Jurisdiction:	Alabama
Legal type:	Domestic Professional Corporation
Status:	Dissolved
Date of registration:	27 Jul 2005 (19 years ago)
Date of dissolution:	10 May 2016
Entity Number:	000-242-721
Register Number:	000242721
County:	Houston
Place of Formation:	Houston County
Principal Address:	DOTHAN, AL
Registered Office Street Address:	1836 WEST MAIN STDOTHAN, AL 36301
Registered Office Street Address ZIP Code:	36301
Authorized Capital:	$1,200

Activities MEDICAL SERVICES

National Provider Identifier

NPI

Enumeration Date

Last Update Date

Mailing Address

Practice Location Address

1235238635

2006-09-22

2008-03-24

1836 W MAIN ST, DOTHAN, AL, 363011320, US

Contacts

Phone	+1 334-699-8585
Fax	3346998587

Authorized person

Name	MR. MIMS HACKETT
Role	ADMINISTRATOR
Phone	3346998585

Taxonomy

Taxonomy Code	207Q00000X - Family Medicine Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	BCBS
Number	51530696
State	AL

form 5500

Plan Name

Plan Year

EIN/PN

Received

Sponsor

Total number of participants

WIREGRASS FAMILY PRACTICE OF DOTHAN, P.C. 401K PLAN

2011

203068849

2012-10-15

WIREGRASS FAMILY PRACTICE OF DOTHAN, P.C.

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2006-01-01
Business code	621111
Sponsor’s telephone number	3346998585
Plan sponsor’s address	1836 WEST MAIN STREET, DOTHAN, AL, 36303

Plan administrator’s name and address

Administrator’s EIN	203068849
Plan administrator’s name	WIREGRASS FAMILY PRACTICE OF DOTHAN, P.C.
Plan administrator’s address	1836 WEST MAIN STREET, DOTHAN, AL, 36303
Administrator’s telephone number	3346998585

Signature of

Role	Plan administrator
Date	2012-10-15
Name of individual signing	TRACI G. HACKETT, MD

Agent

Name	Role
HACKETT, TRACI G	Agent

Incorporator

Name	Role
HACKETT, TRACI G	Incorporator

Date of last update: 02 Aug 2024

Sources: Alabama Secretary of State