=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376732388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE LAZER EYE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 05/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44000 W 12 MILE RD SUITE 112
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-792-3891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44000 W 12 MILE RD
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48377-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-792-3891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PREIDENT
-----------------------------------------------------
Name | DR. SHABBIR KHAMBATI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 586-792-3891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | SK070791
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------