Name: | Blossomwood Medical P.C. |
Jurisdiction: | Alabama |
Legal type: | Domestic Professional Corporation |
Status: | Exists |
Date of registration: | 17 Jul 2009 (15 years ago) |
Entity Number: | 000-261-489 |
Register Number: | 000261489 |
County: | Madison |
Place of Formation: | Madison County |
Principal Address: | HUNTSVILLE, AL |
Registered Office Street Address: | 1508 BIG COVE RDHUNTSVILLE, AL 35801 |
Registered Office Street Address ZIP Code: | 35801 |
Authorized Capital: | 100 |
Activities
GENERAL MEDICAL PRIVATE PRACTICE
NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1144451311 | 2009-08-05 | 2013-02-04 | 2121 WHITESBURG DR SE, SUITE C, HUNTSVILLE, AL, 358014501, US | 2121 WHITESBURG DR SE, SUITE C, HUNTSVILLE, AL, 358014501, US | |||||||||||||||||||||||||
|
Phone | +1 256-883-0107 |
Fax | 2568830207 |
Authorized person
Name | DR. VYTAUTAS PUKIS |
Role | PHYSICIAN |
Phone | 2564319257 |
Taxonomy
Taxonomy Code | 207R00000X - Internal Medicine Physician |
License Number | MD29689 |
State | AL |
Is Primary | Yes |
Other Provider Identifiers
Issuer | MEDICAID |
Number | 113285 |
State | AL |
Name | Role | Address |
---|---|---|
GALLO, EILEEN | Incorporator | 101 N BRAND BLVD 11TH FLOORGLENDALE, CA 91203 |
Name | Role | Address |
---|---|---|
JUCEVICIUTE, DZENE | Agent | 1508 BIG COVE ROADHUNTSVILLE, AL 35801 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State