Provider Demographics
NPI:1235442435
Name:WATTS PRIMARY CARE, PSC
Entity Type:Organization
Organization Name:WATTS PRIMARY CARE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:TALISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:313-465-9892
Mailing Address - Street 1:34390 COUNTRY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3161
Mailing Address - Country:US
Mailing Address - Phone:313-465-9892
Mailing Address - Fax:
Practice Address - Street 1:29425 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 125
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1080
Practice Address - Country:US
Practice Address - Phone:248-569-7550
Practice Address - Fax:248-569-7552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704246644261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care