MEDICARE: PROHEALTH SELMA, 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1831190263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROHEALTH SELMA, INC

Provider Business Mailing Address
First Line	:	PO BOX 681151
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37068-1151
Country	:	US
Telephone Number	:	615-591-4750
Fax Number	:	615-591-4737

Provider Business Practice Location Address
First Line	:	1107 VOEGLIN AVE
Second Line	:
City	:	SELMA
State	:	AL
Zip	:	36703-4301
Country	:	US
Telephone Number	:	334-418-5081
Fax Number	:	334-418-5083

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. RAY WHITE
Credential	:	PHD
Telephone Number	:	334-418-5081

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	09/05/2007

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