Provider Demographics
NPI:1407012966
Name:SEL GROUP
Entity type:Organization
Organization Name:SEL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFONZO
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-285-7173
Mailing Address - Street 1:1589 SKEET CLUB ROAD
Mailing Address - Street 2:SUITE 102 - PMB 322
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265
Mailing Address - Country:US
Mailing Address - Phone:336-285-7173
Mailing Address - Fax:336-285-7174
Practice Address - Street 1:717 GREEN VALLEY ROAD
Practice Address - Street 2:SUITE 200, OFFICE 225
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408
Practice Address - Country:US
Practice Address - Phone:336-285-7173
Practice Address - Fax:336-285-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006655Medicaid