Healthcare Provider Details

I. General information

NPI: 1134023112
Provider Name (Legal Business Name): SELA ACKERMAN HOTHERSALL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 RIDENOUR BLVD NW STE 201
KENNESAW GA
30152-4464
US

IV. Provider business mailing address

1615 RIDENOUR BLVD NW STE 201
KENNESAW GA
30152-4464
US

V. Phone/Fax

Practice location:
  • Phone: 770-499-2020
  • Fax:
Mailing address:
  • Phone: 770-499-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003772
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: