Provider Demographics
NPI:1760035380
Name:LOVELACE POSITIVE IMAGE SERVICES
Entity Type:Organization
Organization Name:LOVELACE POSITIVE IMAGE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PENNYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-909-6984
Mailing Address - Street 1:19726 HAMBURG ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1656
Mailing Address - Country:US
Mailing Address - Phone:313-909-6984
Mailing Address - Fax:
Practice Address - Street 1:1121 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2857
Practice Address - Country:US
Practice Address - Phone:313-365-3100
Practice Address - Fax:313-365-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty