| Name: | Southern Family Practice, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 01 Oct 2008 (16 years ago) (Companies founded in October 2008) |
| Entity Number: | 000-425-647 |
| Register Number: | 000425647 |
| ZIP code: | 36340 (Companies in Geneva, 36340) |
| County: | Geneva |
| Place of Formation: | Geneva County |
| Principal Address: | GENEVA, AL |
| Registered Office Street Address: | 100 WESTLAKE PROFESSIONAL PARKGENEVA, AL 36340 |
Activities
ANY LAWFUL ACTIVITY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1770734543 | 2008-10-09 | 2009-03-23 | 100 W LAKE PROFESSIONAL PARK STE 1, GENEVA, AL, 363401200, US | 100 W LAKE PROFESSIONAL PARK STE 1, GENEVA, AL, 363401200, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 334-684-9400 |
| Fax | 3346846262 |
Authorized person
| Name | MRS. CECILIA RENEE ROBINSON |
| Role | NURSE PRACTITIONER |
| Phone | 3346849400 |
Taxonomy
| Taxonomy Code | 363L00000X - Nurse Practitioner |
| License Number | 1-074572 |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUECROSS BLUESHIELD OF AL. |
| Number | 051593913 |
| State | AL |
| Issuer | MEDICAID |
| Number | 108157 |
| State | AL |
| Issuer | MEDICARE OF ALABAMA |
| Number | 510G700444 |
| State | AL |
| Name | Role |
|---|---|
| CHUMNEY, DONNA F | Agent |
| Name | Role |
|---|---|
| ROBINSON, CECILIA R | Member |
| CHUNMEY, DONNA F | Member |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
