MEDICARE: SELAH GENOMICS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1003104597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELAH GENOMICS INC

Provider Business Mailing Address
First Line	:	411 UNIVERSITY RDG
Second Line	:	NEXT CENTER, SUITE A
City	:	GREENVILLE
State	:	SC
Zip	:	29601-3762
Country	:	US
Telephone Number	:	864-751-4815
Fax Number	:	864-751-4825

Provider Business Practice Location Address
First Line	:	411 UNIVERSITY RDG
Second Line	:	NEXT CENTER, SUITE A
City	:	GREENVILLE
State	:	SC
Zip	:	29601-3762
Country	:	US
Telephone Number	:	864-751-4815
Fax Number	:	864-751-4825

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL BOLICK
Credential	:
Telephone Number	:	864-751-4815

Provider Enumeration Date	:	07/18/2011
Last Update Date	:	10/18/2013

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