| Name: | Johnson's FUNctional Village LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 09 Feb 2021 (4 years ago) (Companies founded in February 2021) |
| Entity Number: | 000-834-503 |
| Register Number: | 000834503 |
| ZIP code: | 35824 (Companies in Madison, 35824) |
| County: | Madison |
| Place of Formation: | Alabama |
| Registered Office Street Address: | 1104 Lakefront DriveHuntsville, AL 35824 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1184203010 | 2021-04-07 | 2021-04-07 | 8000 MADISON BLVD STE D102-208, MADISON, AL, 357582031, US | 8000 MADISON BLVD STE D102-208, MADISON, AL, 357582031, US | |||||||||||||||||||||
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| Phone | +1 256-299-5380 |
| Fax | 2564643045 |
Authorized person
| Name | MRS. KATTIA-NYDE CHAMPAGNE JOHNSON |
| Role | OCCUPATIONAL THERAPIST |
| Phone | 2562995380 |
Taxonomy
| Taxonomy Code | 225XP0200X - Pediatric Occupational Therapist |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1225481781 |
| State | AL |
| Name | Role |
|---|---|
| Johnson, Kattia-Nyde C | Agent |
Date of last update: 16 Aug 2024
Sources: Alabama Secretary of State
