Healthcare Provider Details

I. General information

NPI: 1104298512
Provider Name (Legal Business Name): PRIMAL HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2015
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18530 MACK AVE # 454
GROSSE POINTE FARMS MI
48236-3254
US

IV. Provider business mailing address

18530 MACK AVE # 454
GROSSE POINTE FARMS MI
48236-3254
US

V. Phone/Fax

Practice location:
  • Phone: 313-884-8440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA MORTEN
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 313-355-2841