MEDICARE: PROVEMONT FAMILY CARE, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	5101016681	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1164458295	OTHER		NPI

General Provider Information

NPI Number	:	1013109214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVEMONT FAMILY CARE, PLC

Provider Business Mailing Address
First Line	:	PO BOX 180
Second Line	:
City	:	LAKE LEELANAU
State	:	MI
Zip	:	49653-0180
Country	:	US
Telephone Number	:	231-256-0606
Fax Number	:	231-256-0671

Provider Business Practice Location Address
First Line	:	49 N EAGLE HWY
Second Line	:
City	:	LAKE LEELANAU
State	:	MI
Zip	:	49653-9778
Country	:	US
Telephone Number	:	231-256-0606
Fax Number	:	231-256-0671

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DONA D. ALBA
Credential	:	DO
Telephone Number	:	231-256-0606

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	08/13/2007

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