| Name: | J. Waid Blackstone M.D., LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 15 Apr 2005 (20 years ago) |
| Entity Number: | 000-463-326 |
| Register Number: | 000463326 |
| ZIP code: | 35242 |
| County: | Shelby |
| Place of Formation: | Shelby County |
| Principal Address: | BIRMINGHAM, AL 35242 |
| Registered Office Street Address: | 155 INDIAN GATE CIRCLEBIRMINGHAM, AL 35242 |
Activities
OPHTHALMOLOGY PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1285843888 | 2007-05-21 | 2020-08-22 | 210 W SPRING ST, SYLACAUGA, AL, 351502924, US | 210 W SPRING ST, SYLACAUGA, AL, 351502924, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 256-245-5203 |
| Fax | 2562455981 |
Authorized person
| Name | DR. JAMES WAID BLACKSTONE |
| Role | OWNER |
| Phone | 2562455203 |
Taxonomy
| Taxonomy Code | 261Q00000X - Clinic/Center |
| License Number | 24790 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | AETNA |
| Number | 7514689 |
| State | AL |
| Name | Role |
|---|---|
| BLACKSTONE, J WAID | Agent |
| Name | Role |
|---|---|
| BLACKSTONE, J WAID | Member |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
