Healthcare Provider Details

I. General information

NPI: 1225582687
Provider Name (Legal Business Name): WATTS PRIMARY CARE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34390 COUNTRY MEADOW RD
CHESTERFIELD MI
48047-3161
US

IV. Provider business mailing address

34390 COUNTRY MEADOW RD
CHESTERFIELD MI
48047-3161
US

V. Phone/Fax

Practice location:
  • Phone: 313-465-9892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704246644
License Number StateMI

VIII. Authorized Official

Name: TALISHA WATTS
Title or Position: CEO
Credential: DNP
Phone: 313-465-9892