MEDICARE: MRS. SELINA Y ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	372600000X	Adult Companion	GA
2	3747A0650X	Attendant Care Provider
3	376K00000X	Nurse's Aide	GA

General Provider Information

NPI Number	:	1326343765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SELINA Y ELLIS

Provider Business Mailing Address
First Line	:	PO BOX 81314
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-9314
Country	:	US
Telephone Number	:	770-679-5714
Fax Number	:	888-273-6606

Provider Business Practice Location Address
First Line	:	2055 GEES MILL RD NE
Second Line	:	SUITE 327
City	:	CONYERS
State	:	GA
Zip	:	30013-1362
Country	:	US
Telephone Number	:	770-679-5714
Fax Number	:	888-273-6606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2011
Last Update Date	:	09/26/2012

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