Provider Demographics
NPI:1891841599
Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Entity Type:Organization
Organization Name:SELMA FAMILY PRACTICE OPTOMETRY, INC.
Other - Org Name:EYEMAX VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD MPH
Authorized Official - Phone:334-872-2321
Mailing Address - Street 1:32510 HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-1611
Mailing Address - Country:US
Mailing Address - Phone:334-636-0016
Mailing Address - Fax:334-636-9734
Practice Address - Street 1:32510 HIGHWAY 43N
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-1622
Practice Address - Country:US
Practice Address - Phone:334-636-0016
Practice Address - Fax:334-636-9734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2010-10-25
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
AL51055528OtherBLUE CROSS
AL000055528Medicaid
T68979Medicare UPIN
AL000055528Medicaid
AL0126470001Medicare NSC