| Name: | Selma Family Practice Optometry, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Exists |
| Date of registration: | 10 Mar 2000 (25 years ago) (Companies founded in March 2000) |
| Entity Number: | 000-208-351 |
| Register Number: | 000208351 |
| ZIP code: | 36701 (Companies in Dallas, 36701) |
| County: | Dallas |
| Place of Formation: | Dallas County |
| Principal Address: | SELMA, AL |
| Registered Office Street Address: | 1522 BROAD STSELMA, AL 36701 |
| Authorized Capital: | $1,000 |
| Paid Share Capital: | $1,000 |
Activities
PRACTICE OPTOMETRIC MEDICINE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1891841599 | 2007-01-26 | 2010-10-25 | 32510 HIGHWAY 43, THOMASVILLE, AL, 367841611, US | 32510 HIGHWAY 43N, THOMASVILLE, AL, 367841622, US | |||||||||||||||||||||||||||||||
|
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| Phone | +1 334-636-0016 |
| Fax | 3346369734 |
Authorized person
| Name | DR. LEROY MAXWELL SR. |
| Role | OPTOMETRIST |
| Phone | 3348722321 |
Taxonomy
| Taxonomy Code | 152W00000X - Optometrist |
| License Number | S435TA115 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS |
| Number | 51055528 |
| State | AL |
| Issuer | MEDICAID |
| Number | 000055528 |
| State | AL |
| Name | Role |
|---|---|
| MAXWELL, LEROY SR | Agent |
| Name | Role |
|---|---|
| MAXWELL, LEROY SR | Incorporator |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2010-12-30 | Name Merged | No data | Maxwell Eyemax Vision Centers, Inc. |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
