Provider Demographics
NPI:1871677260
Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Entity type:Organization
Organization Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:334-872-2321
Mailing Address - Street 1:2401 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7756
Mailing Address - Country:US
Mailing Address - Phone:334-872-2321
Mailing Address - Fax:
Practice Address - Street 1:2401 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7756
Practice Address - Country:US
Practice Address - Phone:334-872-2321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-435-TA-115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51095573OtherBLUE CROSS
AL000095573Medicaid
AL529904900OtherGROUP NUMBER
AL0126470001Medicare NSC
ALI767Medicare PIN
ALT68979Medicare UPIN
AL000095573Medicare ID - Type UnspecifiedMEDICARE PROVIDER