Provider Demographics
NPI:1831190263
Name:PROHEALTH SELMA, INC
Entity type:Organization
Organization Name:PROHEALTH SELMA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:334-418-5081
Mailing Address - Street 1:PO BOX 681151
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1151
Mailing Address - Country:US
Mailing Address - Phone:615-591-4750
Mailing Address - Fax:615-591-4737
Practice Address - Street 1:1107 VOEGLIN AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36703-4301
Practice Address - Country:US
Practice Address - Phone:334-418-5081
Practice Address - Fax:334-418-5083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-1882Medicare Oscar/Certification