Provider Demographics
NPI:1447610704
Name:PROVIDER SERVICE ORGANIZATION
Entity Type:Organization
Organization Name:PROVIDER SERVICE ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-516-4239
Mailing Address - Street 1:7233 PROVINCIAL CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2121
Mailing Address - Country:US
Mailing Address - Phone:734-516-4239
Mailing Address - Fax:734-404-5292
Practice Address - Street 1:7233 PROVINCIAL CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2121
Practice Address - Country:US
Practice Address - Phone:734-516-4239
Practice Address - Fax:734-404-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty