| Name: | WellnessConnect Healthcare and Preventive Medicine, L.L.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 30 May 2018 (6 years ago) |
| Entity Number: | 000-520-195 |
| Register Number: | 000520195 |
| County: | Limestone |
| Place of Formation: | Madison County |
| Registered Office Street Address: | 38 AUTUMN ASHE RDMADISON, AL 35756 |
| Registered Office Street Address ZIP Code: | 35756 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1699268672 | 2018-06-13 | 2018-06-13 | 2011 GALLATIN ST SW, HUNTSVILLE, AL, 358014510, US | 2011 GALLATIN ST SW, HUNTSVILLE, AL, 358014510, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 256-907-2493 |
| Fax | 2569071726 |
| Fax | 2562818134 |
Authorized person
| Name | JACKIE COPELAND |
| Role | BILLING MANAGER/CREDENTIALING |
| Phone | 2569072493 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | 00013209 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 2081P2900X - Pain Medicine (Physical Medicine & Rehabilitation) Physician |
| License Number | MD13209 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 2083B0002X - Obesity Medicine (Preventive Medicine) Physician |
| License Number | MD13209 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | NPI |
| Number | 1285741553 |
| State | AL |
| Issuer | NPI |
| Number | 1760437313 |
| State | AL |
| Issuer | NPI |
| Number | 1912186032 |
| State | AL |
| Name | Role |
|---|---|
| WARD, CRAIG | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
