AQUA Dermatology of Alabama, P.C.

Contacts

Phone	+1 205-977-9876
Fax	2059779976

Authorized person

Name	KAREN LAKE
Role	ADMINISTRATION
Phone	2059779786

Taxonomy

Taxonomy Code	207N00000X - Dermatology Physician
License Number	20579
State	AL
Is Primary	No
Taxonomy Code	207ND0101X - MOHS-Micrographic Surgery Physician
License Number	20579
State	AL
Is Primary	Yes
Taxonomy Code	207NS0135X - Procedural Dermatology Physician
License Number	20579
State	AL
Is Primary	No

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, VESTAVIA HILLS, AL, 352422325

Signature of

Role	Plan administrator
Date	2024-08-05
Name of individual signing	CHRISTOPHER B HARMON

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, VESTAVIA HILLS, AL, 352422325

Signature of

Role	Plan administrator
Date	2024-07-21
Name of individual signing	CHRISTOPHER B HARMON

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, SUITE 130, VESTAVIA HILLS, AL, 352422525

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, SUITE 130, VESTAVIA HILLS, AL, 352422525

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, SUITE 30, VESTAVIA HILLS, AL, 352422525

Signature of

Role	Plan administrator
Date	2023-07-12
Name of individual signing	CHRISTOPHER B HARMON

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, SUITE 30, VESTAVIA HILLS, AL, 352422525

Signature of

Role	Plan administrator
Date	2022-09-23
Name of individual signing	CHRISTOPHER B HARMON

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1950 STONEGATE DRIVE, SUITE 130, VESTAVIA HILLS, AL, 352422525

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1940 STONEGATE DRIVE, SUITE 30, VESTAVIA HILLS, AL, 352422525

Signature of

Role	Plan administrator
Date	2021-08-10
Name of individual signing	CHRISTOPHER B HARMON

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1950 STONEGATE DRIVE, SUITE 130, VESTAVIA HILLS, AL, 352422525

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2009-01-01
Business code	621111
Sponsor’s telephone number	2059779876
Plan sponsor’s address	1950 STONEGATE DRIVE, SUITE 30, VESTAVIA HILLS, AL, 352422525