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BETHANY MEDICAL CLINIC, LLC

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Company Details

Name: BETHANY MEDICAL CLINIC, LLC
Jurisdiction: MISSISSIPPI
Business Type: Limited Liability Company
Status: Dissolved
Effective Date: 01 Jan 2004 (22 years ago)
Business ID: 740221
State of Incorporation: MISSISSIPPI

Agent

Name Role Address
W ELLIS PITTMAN Agent 315 DESOTO AVE, P O BOX 1670, CLARKSDALE, MS 38614-1670

Member

Name Role Address
CHARLENE BRANDON Member ROSEMARY RD, CLARKSDALE, MS 38732-358
ANDRE KIRKLANE Member ROSEMARY RD P O BOX 358, CLEVELAND, MS 38732-358

National Provider Identifier

NPI Number:
1487792032

Authorized Person:

Name:
MR. RICKY MOORE
Role:
INS. CLERK
Phone:

Taxonomy:

Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
Yes

Contacts:

Fax:
6628465034

Filings

Type Status Filed Date Description
Failure to File AR Filed 2011-12-05 Failure to File AR
Amendment Form Filed 2009-08-28 Amendment
See File Filed 2003-12-15 See File
Amendment Form Filed 2003-12-15 Amendment
Name Reservation Form Filed 2003-10-07 Name Reservation

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Date of last update: 30 Jun 2025

Sources: Company Profile on Mississippi Secretary of State Website