MEDICARE: S.E.L. THERAPEUTICS, LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1174302822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S.E.L. THERAPEUTICS, LLC

Provider Business Mailing Address
First Line	:	200 WILKIN ST APT 209
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-4430
Country	:	US
Telephone Number	:	612-598-0824
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WILKIN ST APT 209
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-4430
Country	:	US
Telephone Number	:	612-598-0824
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IDIL HIRSI
Credential	:
Telephone Number	:	612-598-0824

Provider Enumeration Date	:	09/22/2023
Last Update Date	:	09/22/2023

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