| Name: | Dermatology Associates of Dothan, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 31 Aug 2000 (24 years ago) |
| Entity Number: | 000-671-544 |
| Register Number: | 000671544 |
| Historical Names: |
Cosmetic Surgery Of The Southeast LLC
|
| Place of Formation: | Houston County |
| Principal Address: | DOTHAN, AL |
| Registered Office Street Address: | 2431 WEST MAIN ST STE 501DOTHAN, AL 36301-1274 |
Activities
OWN/OPERATE A MEDICAL DERMATOLOGY/COSMETIC CLINIC
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1538465323 | 2011-01-27 | 2011-01-27 | 2431 W MAIN ST STE 501, DOTHAN, AL, 363011274, US | 101 PROFESSIONAL LN, ENTERPRISE, AL, 363302085, US | |||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
| Phone | +1 334-793-9222 |
| Fax | 3346710322 |
| Phone | +1 334-347-3404 |
Authorized person
| Name | DR. TERRY L PYNES |
| Role | OWNER |
| Phone | 3347939222 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 8834 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS OF ALABAMA |
| Number | 51007184 |
| State | AL |
| Issuer | MEDICAID |
| Number | 529932951 |
| State | AL |
| Name | Role |
|---|---|
| PYNES, L TERRY | Agent |
| Name | Role |
|---|---|
| PYNES, L TERRY | Member |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2004-04-07 | Name Change | Cosmetic Surgery Of The Southeast LLC | Dermatology Associates of Dothan, LLC |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
