| Organization Name: | PROVEMONT FAMILY CARE, PLC |
| NPI Number: | 1013109214 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DONA D. ALBA (PRESIDENT) |
| Mailing Address: | 49 N Eagle Hwy Lake Leelanau |
| State: | MI US |
| Postal Code: | 496539778 |
| Phone Number: | 2312560606 |
| Fax Number: | 2312560671 |
| NPI Enumeration Date: | 08/13/2007 |
| NPI Last Update Date: | 08/13/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 5101016681 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |