Provider Demographics
NPI:1518144641
Name:SOPHA, SHIRLEY (ABOC)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:SOPHA
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64207 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2579
Mailing Address - Country:US
Mailing Address - Phone:586-336-4566
Mailing Address - Fax:
Practice Address - Street 1:64207 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48095-2579
Practice Address - Country:US
Practice Address - Phone:586-336-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI166899156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician