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General NPI Number Information
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NPI Number | 1104971803
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Entity Type | Organization
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Legal Business Name | SELMA FAMILY PRACTICE OPTOMETRY, INC.
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 01/24/2011
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Provider Practice Location Address
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Address Line | 1502 HIGHWAY 80E SUITE A
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City | DEMOPOLIS
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State | AL
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Zip | 36732-0799
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Country | US
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Telephone | 334-289-1008
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Fax | 334-289-1009
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Provider Business Mailing Address
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Address Line | PO BOX 799
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City | DEMOPOLIS
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State | AL
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Zip | 36732-0799
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Country | US
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Telephone | 334-289-1008
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Fax | 334-289-1009
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Authorized Official
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Title or Position | OPTICIAN
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Name | MS. WILLIE F SMITH
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Credential | MANAGER
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Telephone | 334-289-1008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | S435TA115
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License Number State | AL
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