Provider Demographics
NPI:1164932489
Name:KENETHA, SALIM
Entity Type:Individual
Prefix:
First Name:SALIM
Middle Name:
Last Name:KENETHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4864
Mailing Address - Country:US
Mailing Address - Phone:586-693-5060
Mailing Address - Fax:586-693-5060
Practice Address - Street 1:2001 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4864
Practice Address - Country:US
Practice Address - Phone:586-693-5060
Practice Address - Fax:586-693-5060
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI220452156FX1800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician