| Name: | Mtn. Lake Urology, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 01 Jul 2008 (16 years ago) (Companies founded in July 2008) |
| Entity Number: | 000-257-893 |
| Register Number: | 000257893 |
| ZIP code: | 36117 (Companies in Montgomery, 36117) |
| County: | Montgomery |
| Place of Formation: | Montgomery County |
| Principal Address: | MONTGOMERY, AL |
| Registered Office Street Address: | 8620 HALLWOOD DRMONTGOMERY, AL 36117 |
| Authorized Capital: | $1,000 |
Activities
MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1801050364 | 2008-07-14 | 2018-03-21 | 750 BYRON RD, SCOTTSBORO, AL, 357694051, US | 750 BYRON RD, SCOTTSBORO, AL, 357694051, US | |||||||||||||||||||||||||
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| Phone | +1 256-259-8765 |
| Fax | 2567168060 |
Authorized person
| Name | SHERRY GROSS |
| Role | OFFICE MANAGER |
| Phone | 2562598765 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 17993 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 106277 |
| State | AL |
| Name | Role |
|---|---|
| SIMMONS, MICHAEL G | Agent |
| Name | Role |
|---|---|
| SIMMONS, MICHAEL G | Incorporator |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
