Provider Demographics
NPI:1104171602
Name:SHELBY MACOMB VISION ASSOCIATES INC
Entity type:Organization
Organization Name:SHELBY MACOMB VISION ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BASEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:586-806-9333
Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:STE 110
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-806-9333
Mailing Address - Fax:
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:STE 110
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-806-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004569152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty