Healthcare Provider Details

I. General information

NPI: 1669676755
Provider Name (Legal Business Name): MR. GREGORY M SELLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15340A COUNTY ROAD 66
LOXLEY AL
36551-4130
US

IV. Provider business mailing address

15340-A COUNTY ROAD 66
LOXLEY AL
36551-4130
US

V. Phone/Fax

Practice location:
  • Phone: 251-964-8900
  • Fax: 251-964-8901
Mailing address:
  • Phone: 251-964-8900
  • Fax: 251-964-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: