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Southern Divine Family Medical Center, LLC

Details

Name: Southern Divine Family Medical Center, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Exists
Date of registration: 17 Nov 2019 (5 years ago) (Companies founded in November 2019)
Entity Number: 000-596-353
Register Number: 000596353
ZIP code: 35951 (Companies in Marshall, 35951)
County: Marshall
Place of Formation: Marshall County
Registered Office Street Address: 235 BENTBROOK DRIVEALBERTVILLE, AL 35951

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1104456920 2020-01-21 2022-04-09 PO BOX 35, ALTOONA, AL, 359520035, US 7130 6TH AVE, ALTOONA, AL, 359529052, US

Contacts

Phone +1 205-589-1092
Fax 2055891096

Authorized person

Name ENRICO D GASPAR
Role OWNER
Phone 2568408181

Taxonomy

Taxonomy Code 207R00000X - Internal Medicine Physician
Is Primary Yes
Taxonomy Code 363LA2100X - Acute Care Nurse Practitioner
Is Primary No
Taxonomy Code 363LA2200X - Adult Health Nurse Practitioner
Is Primary No
Taxonomy Code 363LF0000X - Family Nurse Practitioner
Is Primary No

Agent

Name Role Address
GASPAR, ENRICO Agent 235 BENTBOOK DRIVEALBERTVILLE, AL 35951

Date of last update: 14 Aug 2024

Sources: Alabama Secretary of State