| Name: | Salem Nursing & Rehab Center of Reform, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Non-Profit Corporation |
| Status: | Exists |
| Date of registration: | 05 Jun 1995 (29 years ago) (Companies founded in June 1995) |
| Entity Number: | 000-935-046 |
| Register Number: | 000935046 |
| ZIP code: | 36104 (Companies in Montgomery, 36104) |
| County: | Montgomery |
| Place of Formation: | Georgia |
| Principal Address: | 500 FLOYD RDCALHOUN, GA 30701 |
| Registered Office Street Address: | 2 NORTH JACKSON ST., SUITE 605MONTGOMERY, AL 36104 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1548293525 | 2006-07-10 | 2014-06-16 | 512 2ND AVE NW, REFORM, AL, 354812332, US | 512 2ND AVE NW, REFORM, AL, 354812332, US | |||||||||||||||||||||||||
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| Phone | +1 205-375-6379 |
| Fax | 2053758283 |
Authorized person
| Name | MR. DOUGLAS K MITTLEIDER |
| Role | PRESIDENT |
| Phone | 7706190866 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | 12664 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 4757680S |
| State | AL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SALEM NURSING & REHAB CENTER OF REFORM FLEXIBLE BENEFITS PLAN | 2013 | 631147318 | 2014-05-05 | SALEM NURSING & REHAB CENTER OF REFORM INC | 34 | |||||||||||||||||||||||||||||||||||||||
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| Active participants | 29 |
Signature of
| Role | Plan administrator |
| Date | 2014-05-05 |
| Name of individual signing | JACKIE SORRELLS |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2014-05-05 |
| Name of individual signing | DOUGLAS K MITTLEIDER |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| C T CORPORATION SYSTEM | Agent | 2 NORHT JACKSON STREET SUITE 605MONTGOMERY, AL 36104 |
Date of last update: 17 Aug 2024
Sources: Alabama Secretary of State
