Healthcare Provider Details

I. General information

NPI: 1760035380
Provider Name (Legal Business Name): LOVELACE POSITIVE IMAGE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

19726 HAMBURG ST
DETROIT MI
48205-1656
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3100
  • Fax: 313-365-3101
Mailing address:
  • Phone: 313-909-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: ALICIA MARIE PENNYMON
Title or Position: CEO
Credential:
Phone: 313-909-6984