Healthcare Provider Details

I. General information

NPI: 1235442435
Provider Name (Legal Business Name): WATTS PRIMARY CARE, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29425 NORTHWESTERN HWY SUITE 125
SOUTHFIELD MI
48034-1080
US

IV. Provider business mailing address

34390 COUNTRY MEADOW RD
CHESTERFIELD MI
48047-3161
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-7550
  • Fax: 248-569-7552
Mailing address:
  • Phone: 313-465-9892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4704246644
License Number StateMI

VIII. Authorized Official

Name: DR. TALISHA L WATTS
Title or Position: ADULT NURSE PRACTITIONER
Credential: DNP
Phone: 313-465-9892