Provider Demographics
NPI:1104971803
Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Entity type:Organization
Organization Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:334-289-1008
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-0799
Mailing Address - Country:US
Mailing Address - Phone:334-289-1008
Mailing Address - Fax:334-289-1009
Practice Address - Street 1:1502 HIGHWAY 80E
Practice Address - Street 2:SUITE A
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-0799
Practice Address - Country:US
Practice Address - Phone:334-289-1008
Practice Address - Fax:334-289-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS435TA115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000055527Medicaid
AL51055527OtherBLUE CROSS
ALI768Medicare PIN
AL000055527Medicaid
AL51055527OtherBLUE CROSS
AL000055527Medicare PIN