| Name: | Provision Health Services L.L.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 13 Feb 2020 (5 years ago) |
| Entity Number: | 000-623-235 |
| Register Number: | 000623235 |
| County: | De Kalb |
| Place of Formation: | DeKalb County |
| Registered Office Street Address: | 415 MEDICAL CENTER DRIVE SWFORT PAYNE, AL 35968 |
| Registered Office Street Address ZIP Code: | 35968 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1578185393 | 2020-05-14 | 2020-05-14 | 415 MEDICAL CENTER DR SW, FORT PAYNE, AL, 359683421, US | 415 MEDICAL CENTER DR SW, FORT PAYNE, AL, 359683421, US | |||||||||||||
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| Phone | +1 256-899-7585 |
Authorized person
| Name | MICHELLE HAWTHORNE |
| Role | CREDENTIALING COORDINATOR |
| Phone | 2052922428 |
Taxonomy
| Taxonomy Code | 363LP0808X - Psychiatric/Mental Health Nurse Practitioner |
| Is Primary | Yes |
| Name | Role |
|---|---|
| PACK, RICHARD | Agent |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
