| Name: | Desselle Surgical Clinic, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 13 Aug 2009 (15 years ago) |
| Date of dissolution: | 30 Dec 2010 |
| Entity Number: | 000-436-957 |
| Register Number: | 000436957 |
| County: | Colbert |
| Place of Formation: | Colbert County |
| Principal Address: | MUSCLE SHOALS, AL |
| Registered Office Street Address: | 203 AVALON AVE STE 290MUSCLE SHOALS, AL 35661 |
| Registered Office Street Address ZIP Code: | 35661 |
Activities
MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1992938930 | 2009-08-25 | 2010-01-06 | 203 AVALON AVE, SUITE 290, MUSCLE SHOALS, AL, 356612855, US | 203 AVALON AVE, SUITE 290, MUSCLE SHOALS, AL, 356612869, US | |||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 256-386-1125 |
| Fax | 2563861126 |
Authorized person
| Name | DIANE H. DAWSON |
| Role | OFFICE MANAGER |
| Phone | 2563861125 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 25005 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1477478 |
| State | LA |
| Issuer | MEDICAID |
| Number | 114470 |
| State | AL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 510-49740 |
| State | AL |
| Issuer | MEDICARE PTAN |
| Number | 102I029080 |
| State | AL |
| Name | Role |
|---|---|
| DESSELLE, WESLEY JOSEPH | Agent |
| Name | Role |
|---|---|
| SURGICAL ASSOCIATES OF THE SHOALS PC | Member |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
