| 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 | |||||||||||||||||||||||||
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| 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
