| Name: | Renew Family Dermatology, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 19 Feb 2019 (6 years ago) |
| Entity Number: | 000-543-952 |
| Register Number: | 000543952 |
| County: | De Kalb |
| Place of Formation: | DeKalb County |
| Registered Office Street Address: | 1403 OLD WATERWORKS ROAD SWFORT PAYNE, AL 35968 |
| Registered Office Street Address ZIP Code: | 35968 |
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| L1KJNKAJKJY6 | 2025-02-11 | 1403 OLD WATER WORKS RD SW, FORT PAYNE, AL, 35968, 3353, USA | PO BOX 680256, FORT PAYNE, AL, 35968, USA | |||||||||||||||||||||||||||||||||||||||
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| Congressional District | 04 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2024-02-14 |
| Initial Registration Date | 2021-01-07 |
| Entity Start Date | 2019-09-12 |
| Fiscal Year End Close Date | Dec 31 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | PAM MASON |
| Role | MANAGER |
| Address | 1403 OLD WATER WORKS RD SW, FORT PAYNE, AL, 35968, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | PAM MASON |
| Role | MANAGER |
| Address | 1403 OLD WATER WORKS RD SW, FORT PAYNE, AL, 35968, USA |
| Past Performance | Information not Available |
|---|
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1275198913 | 2019-05-08 | 2024-06-26 | 212 AIRPORT RD W, FORT PAYNE, AL, 359683335, US | 212 AIRPORT ROAD W, FORT PAYNE, AL, 35968, US | |||||||||||||||||||||||||
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| Phone | +1 256-979-1250 |
| Fax | 2569791251 |
Authorized person
| Name | PAM MASON |
| Role | MANAGER |
| Phone | 2568670851 |
Taxonomy
| Taxonomy Code | 207N00000X - Dermatology Physician |
| Is Primary | Yes |
| Taxonomy Code | 261QM2500X - Medical Specialty Clinic/Center |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 236456 |
| State | AL |
| Name | Role |
|---|---|
| DIGSBY, MICHAEL S | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
