| Name: | Mizell Memorial Hospital Homecare, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 14 Jan 2005 (20 years ago) |
| Entity Number: | 000-459-464 |
| Register Number: | 000459464 |
| County: | Montgomery |
| Place of Formation: | Jefferson County |
| Principal Address: | MONTGOMERY, AL |
| Registered Office Street Address: | 2 N JACKSON STREET, SUITE 605MONTGOMERY, AL 36104 |
| Registered Office Street Address ZIP Code: | 36104 |
Activities
OWN/OPERATE/MANAGE A MEDICARE CERTIFIED HOME HEALTH AGENCY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1033293352 | 2006-10-24 | 2020-12-01 | PO BOX 51266, LAFAYETTE, LA, 705051266, US | 1802 US HIGHWAY 84 W, SUITE A, OPP, AL, 364673520, US | |||||||||||||||||||||||||||||||
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| Phone | +1 337-233-1307 |
| Fax | 3372335764 |
| Phone | +1 334-493-2087 |
| Fax | 3344937285 |
Authorized person
| Name | MR. NICHOLAS GACHASSIN III |
| Role | EXECUTIVE VICE PRESIDENT |
| Phone | 3372331307 |
Taxonomy
| Taxonomy Code | 251E00000X - Home Health Agency |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD OF |
| Number | 515-41052 |
| State | AL |
| Issuer | MEDICAID |
| Number | LHC 7134A |
| State | AL |
| Name | Role | Address |
|---|---|---|
| C T CORPORATION SYSTEM | Agent | 2 NORHT JACKSON STREET SUITE 605MONTGOMERY, AL 36104 |
| Name | Role |
|---|---|
| MIZELL MEMORIAL HOSPITAL INC | Member |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
