| Name: | River Region Family Medicine LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 19 Feb 2020 (5 years ago) |
| Entity Number: | 000-622-827 |
| Register Number: | 000622827 |
| ZIP code: | 36092 |
| County: | Elmore |
| Place of Formation: | Elmore County |
| Registered Office Street Address: | 500 Hospital DriveWetumpka, AL 36092 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1578195525 | 2020-02-07 | 2020-08-20 | PO BOX 130, WETUMPKA, AL, 360920003, US | 277 HUNTRESS STREET, SUITE 100, WETUMPKA, AL, 36092, US | |||||||||||||||||||||||||
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| Phone | +1 334-567-4311 |
Authorized person
| Name | MR. MICHAEL D BRUCE |
| Role | CEO |
| Phone | 2566750412 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 120559 |
| State | AL |
| Issuer | MEDICAID |
| Number | APPLIED |
| State | AL |
| CAGE number | Status | Type | Established | CAGE Update Date | CAGE Expiration | SAM Expiration | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7JL03 | Obsolete | Non-Manufacturer | 2016-01-20 | 2022-01-18 | 2022-01-17 | No data | |||||||||||||
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| POC | AMANDA HANNON |
| Phone | +1 334-567-3309 |
| Address | 41 CAMBRIDGE CT, WETUMPKA, AL, 36093 1261, UNITED STATES |
Ownership of Offeror Information
| Highest Level Owner | Information not Available |
|---|
| Immediate Level Owner | Information not Available |
|---|
| List of Offerors (0) | Information not Available |
|---|
| Name | Role | Address |
|---|---|---|
| IVY CREEK HEALTHCARE LLC | Agent | 16020 SW 80TH AVENUEMIAMI, FL 33157 |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
