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General NPI Number Information
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NPI Number | 1891841599
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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 | 01/26/2007
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Last Update Date | 10/25/2010
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Provider Practice Location Address
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Address Line | 32510 HIGHWAY 43N
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City | THOMASVILLE
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State | AL
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Zip | 36784-1622
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Country | US
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Telephone | 334-636-0016
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Fax | 334-636-9734
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Provider Business Mailing Address
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Address Line | 32510 HIGHWAY 43
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City | THOMASVILLE
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State | AL
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Zip | 36784-1611
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Country | US
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Telephone | 334-636-0016
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Fax | 334-636-9734
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. LEROY MAXWELL SR.
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Credential | O.D M.PH
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Telephone | 334-872-2321
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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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