| Name: | Black Watch Sports Performance, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 22 May 2014 (10 years ago) |
| Entity Number: | 000-310-667 |
| Register Number: | 000310667 |
| County: | Shelby |
| Place of Formation: | Shelby County |
| Principal Address: | 1112 GREYMOOR ROADBIRMINGHAM, AL 35242 |
| Principal Address ZIP Code: | 35242 |
| Registered Office Street Address: | 157 RESOURCE CENTER PARKWAY STE 107BIRMINGHAM, AL 35242 |
| Registered Office Street Address ZIP Code: | 35242 |
Activities
ATHLETIC TRAINING AND SPORTS PERFORMANCE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1730855016 | 2021-08-18 | 2021-08-18 | 157 RESOURCE CENTER PKWY STE 107, BIRMINGHAM, AL, 352428135, US | 157 RESOURCE CENTER PKWY STE 107, BIRMINGHAM, AL, 352428135, US | |||||||||||||||||||||
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| Phone | +1 229-402-3338 |
| Fax | 2054534603 |
Authorized person
| Name | SHELLEY ANNE ANDERSON |
| Role | PHYSICAL THERAPIST |
| Phone | 2294023338 |
Taxonomy
| Taxonomy Code | 261QP2000X - Physical Therapy Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 1255980181 |
| State | AL |
| Name | Role |
|---|---|
| BECKHAM, RANDY K | Agent |
| Name | Role | Address |
|---|---|---|
| BECKHAM, RANDY | Organizer | 1112 GREYMOOR RDBIRMINGHAM, AL 35242 |
Date of last update: 02 Aug 2024
Sources: Alabama Secretary of State
