| Name: | KIDS CLINIC, Pediatric and Adolescent Medicine LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 17 Apr 2018 (7 years ago) (Companies founded in April 2018) |
| Entity Number: | 000-516-000 |
| Register Number: | 000516000 |
| ZIP code: | 35160 (Companies in Talladega, 35160) |
| County: | Talladega |
| Place of Formation: | Saint Clair County |
| Registered Office Street Address: | 119 STEPHEN J WHITE MEMORIAL BLVDTALLADEGA, AL 35160 |
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Y1YHZJKCX2M7 | 2024-07-16 | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 35160, 2106, USA | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 35160, 2106, USA | |||||||||||||||||||||||||||||||||||||||||
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| Doing Business As | KIDS CLINIC PEDIATRIC & ADOLESCENT MED |
| Congressional District | 03 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2023-07-18 |
| Initial Registration Date | 2021-06-08 |
| Entity Start Date | 2018-05-01 |
| Fiscal Year End Close Date | Dec 31 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | NICOLE GURLEY |
| Role | MANAGING DIRECTOR |
| Address | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 35160, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | NICOLE GURLEY |
| Role | MANAGING DIRECTOR |
| Address | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 35160, USA |
| Past Performance | Information not Available |
|---|
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1154810224 | 2018-05-04 | 2023-09-26 | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 351602106, US | 119 STEPHEN J WHITE MEMORIAL BLVD, TALLADEGA, AL, 351602106, US | |||||||||||||||||||||||||
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| Phone | +1 256-268-7775 |
| Fax | 2562687760 |
Authorized person
| Name | DR. MUHAMMED KHURRAM SIDDIQUI |
| Role | OWNER |
| Phone | 2562687775 |
Taxonomy
| Taxonomy Code | 2080A0000X - Pediatric Adolescent Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 000032739 |
| State | AL |
| Issuer | UPIN |
| Number | G50661 |
| Name | Role |
|---|---|
| SIDDIQUI, MUHAMED K | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
