MEDICARE: SELA AQUATICS

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	:	1275111056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SELA AQUATICS

Provider Business Mailing Address
First Line	:	5206 LONE PINE LN
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-3169
Country	:	US
Telephone Number	:	504-451-2979
Fax Number	:

Provider Business Practice Location Address
First Line	:	5206 LONE PINE LN
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-3169
Country	:	US
Telephone Number	:	504-451-2979
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT DOWIE
Credential	:
Telephone Number	:	504-451-2979

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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Directions to “SELA AQUATICS ” Practice Location

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