| 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) |
| Entity Number: | 000-596-353 |
| Register Number: | 000596353 |
| County: | Marshall |
| Place of Formation: | Marshall County |
| Registered Office Street Address: | 235 BENTBROOK DRIVEALBERTVILLE, AL 35951 |
| Registered Office Street Address ZIP Code: | 35951 |
| 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 | |||||||||||||||||||||||||||
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| 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 |
| Name | Role | Address |
|---|---|---|
| GASPAR, ENRICO | Agent | 235 BENTBOOK DRIVEALBERTVILLE, AL 35951 |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
