| Name: | Hicks Home-based Primary Care, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Limited Liability Company |
| Status: | Exists |
| Date of registration: | 05 Nov 2019 (5 years ago) |
| Entity Number: | 000-592-667 |
| Register Number: | 000592667 |
| County: | Mobile |
| Place of Formation: | Mobile County |
| Registered Office Street Address: | 1111 E I-65 SERVICE ROAD S STE 210MOBILE, AL 36606 |
| Registered Office Street Address ZIP Code: | 36606 |
| Registered Office Mailing Address: | 601 VALLIER CTSATSUMA, AL 36572 |
| Registered Office Mailing Address ZIP Code: | 36572 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1679118525 | 2019-11-14 | 2022-03-31 | 1111 E I65 SERVICE RD S STE 210, MOBILE, AL, 366063123, US | 1111 E I65 SERVICE RD S STE 210, MOBILE, AL, 366063123, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 251-408-7568 |
Authorized person
| Name | DR. WANDA DENISE HICKS |
| Role | CEO AND FOUNDER |
| Phone | 2514087568 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BC/BS |
| Number | 1033206545 |
| State | AL |
| Issuer | PRIVATE INSURANCES |
| Number | 1033206545 |
| State | AL |
| Issuer | MEDICAID |
| Number | 1033206545 |
| State | AL |
| Issuer | UNITED HEALTH |
| Number | 1033206545 |
| State | AL |
| Name | Role |
|---|---|
| HICKS, WANDA | Agent |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
