Healthcare Provider Details

I. General information

NPI: 1740626928
Provider Name (Legal Business Name): SELMA DALLAS PREVENTION COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BELL RD
SELMA AL
36701-6703
US

IV. Provider business mailing address

PO BOX 525 1 BELL ROAD
SELMA AL
36702-0525
US

V. Phone/Fax

Practice location:
  • Phone: 334-526-2500
  • Fax: 334-526-2502
Mailing address:
  • Phone: 334-526-2500
  • Fax: 334-526-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. COLEY C. CHESTNUT SR.
Title or Position: DIRECTOR
Credential: MS, MMIN
Phone: 334-526-2500