Provider Demographics
NPI:1366678187
Name:TRACEY W SELLERS
Entity Type:Organization
Organization Name:TRACEY W SELLERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:WYNNE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-746-7313
Mailing Address - Street 1:111 CLEBOURNE ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-1758
Mailing Address - Country:US
Mailing Address - Phone:803-746-7313
Mailing Address - Fax:803-746-7332
Practice Address - Street 1:111 CLEBOURNE ST
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-1758
Practice Address - Country:US
Practice Address - Phone:803-746-7313
Practice Address - Fax:803-746-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3248261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center