| Name: | Ross Clark Circle Dialysis, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Limited Liability Company |
| Status: | Exists |
| Date of registration: | 04 Jan 2008 (17 years ago) |
| Entity Number: | 000-614-823 |
| Register Number: | 000614823 |
| County: | Montgomery |
| Place of Formation: | Delaware |
| Principal Address: | 601 HAWAII STREETEL SEGUNDO, CA 90245 |
| Principal Mailing Address: | 3715 NORTHSIDE PKWY NW 1-315ATLANTA, GA 30327 |
| Registered Office Street Address: | 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104 |
| Registered Office Street Address ZIP Code: | 36104 |
Activities
KIDNEY DIALYSIS SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003070285 | 2008-07-16 | 2024-03-06 | 5200 VIRGINIA WAY, L&C DEPT, BRENTWOOD, TN, 370277569, US | 1450 ROSS CLARK CIR, STE 200, DOTHAN, AL, 363014770, US | |||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 615-320-4268 |
| Fax | 8772380567 |
| Phone | +1 334-792-8907 |
| Fax | 3347928912 |
Authorized person
| Name | SAMUEL T. WEY |
| Role | VP, LICENSURE & CERTIFICATION |
| Phone | 6153416641 |
Taxonomy
| Taxonomy Code | 261QE0700X - End-Stage Renal Disease (ESRD) Treatment Clinic/Center |
| License Number | S3503 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 008910100 |
| State | FL |
| Issuer | MEDICAID |
| Number | 067833571A |
| State | GA |
| Issuer | MEDICAID |
| Number | 1003070285 |
| State | AL |
| CAGE number | Status | Type | Established | CAGE Update Date | CAGE Expiration | SAM Expiration | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5XSL0 | Active | Non-Manufacturer | 2010-03-22 | 2023-11-23 | 2027-11-26 | 2023-11-23 | |||||||||||||||||||||
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| POC | COURTNEY DUDLEY |
| Phone | +1 253-382-1340 |
| Address | 1450 ROSS CLARK CIR, DOTHAN, AL, 36301 4770, UNITED STATES |
Ownership of Offeror Information
| Highest Level Owner | Information not Available |
|---|
| Immediate Level Owner | |
|---|---|
| Vendor Certified | 2022-11-26 |
| CAGE number | 45JM2 |
| Company Name | DAVITA INC. |
| CAGE Last Updated | 2024-03-29 |
| List of Offerors (0) | Information not Available |
|---|
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY INC | Agent | 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808 |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
