| Name: | Shoals Infectious Disease Consultants, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 18 Jul 2018 (6 years ago) |
| Entity Number: | 000-524-634 |
| Register Number: | 000524634 |
| County: | Lauderdale |
| Place of Formation: | Lauderdale County |
| Registered Office Street Address: | 142 BLACKBERRY TRAILFLORENCE, AL 35630 |
| Registered Office Street Address ZIP Code: | 35630 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1083192173 | 2018-08-01 | 2021-08-23 | PO BOX 1077, FLORENCE, AL, 35630, US | 22281 US HIGHWAY 72 STE A, ATHENS, AL, 356132601, US | |||||||||||||||||||||||||||||||||||
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| Phone | +1 256-444-4401 |
| Fax | 2564444403 |
Authorized person
| Name | JEAN HILAIRE VINCENT |
| Role | OWNER |
| Phone | 2564444401 |
Taxonomy
| Taxonomy Code | 163WW0000X - Wound Care Registered Nurse |
| License Number | 180531025 |
| Is Primary | No |
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | MD.36985 |
| Is Primary | No |
| Taxonomy Code | 207RI0200X - Infectious Disease Physician |
| License Number | MD.36985 |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 219543 |
| State | AL |
| Name | Role |
|---|---|
| VINCENT, JEAN H | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
