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General NPI Number Information
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NPI Number | 1699949610
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Entity Type | Organization
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Legal Business Name | FENTON CLINIC
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 201 E CAROLINE ST 129
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City | FENTON
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State | MI
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Zip | 48430-2105
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Country | US
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Telephone | 810-629-4187
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Fax | 810-629-9662
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Provider Business Mailing Address
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Address Line | 201 E CAROLINE ST 129
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City | FENTON
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State | MI
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Zip | 48430-2105
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Country | US
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Telephone | 810-629-4187
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Fax | 810-629-9662
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOSEPH LAVERN TROLLMAN JR.
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Credential | DO
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Telephone | 810-629-4187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 51010055954
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License Number State | MI
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