Healthcare Provider Details

I. General information

NPI: 1245086750
Provider Name (Legal Business Name): HEALTHSPAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18450 MACK AVE STE 101
GROSSE POINTE FARMS MI
48236-3222
US

IV. Provider business mailing address

18450 MACK AVE STE 101
GROSSE POINTE FARMS MI
48236-3222
US

V. Phone/Fax

Practice location:
  • Phone: 313-583-4333
  • Fax: 313-432-8135
Mailing address:
  • Phone: 313-583-4333
  • Fax: 313-432-8135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GINETTE GOMEZ
Title or Position: CARDIOLOGIST/OWNER
Credential: DO
Phone: 313-583-4333