| Name: | Forme Medical and Burgess Chiropractic Clinic, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 13 Jul 2001 (23 years ago) |
| Date of dissolution: | 09 Aug 2019 |
| Entity Number: | 000-676-702 |
| Register Number: | 000676702 |
| Historical Names: |
Burgess Chiropractic and Forme Medical and Rehab, LLC
|
| County: | Calhoun |
| Place of Formation: | Calhoun County |
| Principal Address: | ANNISTON, AL |
| Registered Office Street Address: | 3001 MCCLELLAN BLVDANNISTON, AL 36201 |
| Registered Office Street Address ZIP Code: | 36201 |
Activities
CHIROPRACTIC/MEDICAL/PHYSICAL THERAPY SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1356466379 | 2007-03-20 | 2008-11-19 | 3001 MCCLELLAN BLVD, ANNISTON, AL, 362012724, US | 3001 MCCLELLAN BLVD, ANNISTON, AL, 362012724, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 256-237-9251 |
| Fax | 2562367397 |
Authorized person
| Name | DR. DALE C BURGESS |
| Role | DOCTOR OF CHIROPRACTIC |
| Phone | 2562379251 |
Taxonomy
| Taxonomy Code | 111N00000X - Chiropractor |
| License Number | 915 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BC PROVIDER # |
| Number | 51505603 |
| State | AL |
| Name | Role |
|---|---|
| BURGESS, DALE C | Agent |
| Name | Role |
|---|---|
| BURGESS, DALE C | Member |
| BURGESS, JODI J | Member |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2002-04-22 | Name Change | Burgess Chiropractic and Forme Medical and Rehab, LLC | Forme Medical and Burgess Chiropractic Clinic, LLC |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
