=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235442435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATTS PRIMARY CARE, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2010
-----------------------------------------------------
Last Update Date | 11/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29425 NORTHWESTERN HWY SUITE 125
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-569-7550
-----------------------------------------------------
Fax | 248-569-7552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34390 COUNTRY MEADOW RD
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48047-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-465-9892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADULT NURSE PRACTITIONER
-----------------------------------------------------
Name | DR. TALISHA L WATTS
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 313-465-9892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 4704246644
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------