MEDICARE: LARRY'S FULL SERVICE SALON

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	385H00000X	Respite Care	1865788	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1865788	OTHER	MI	STATE OF MICHIGAN HOME HELP CARE PROVIDER#1865788(2003)-PRESENT

General Provider Information

NPI Number	:	1013289438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY'S FULL SERVICE SALON

Provider Business Mailing Address
First Line	:	10658 ALPINE DR
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9722
Country	:	US
Telephone Number	:	989-544-2200
Fax Number	:

Provider Business Practice Location Address
First Line	:	10658 ALPINE DR
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9722
Country	:	US
Telephone Number	:	989-544-2200
Fax Number	:

Authorized Official
Title or Position	:	OPPERATOR
Name	:	MR. LARRY EUGENE CLAYBAUGH JR.
Credential	:	CAREGIVER
Telephone Number	:	989-544-2200

Provider Enumeration Date	:	01/31/2012
Last Update Date	:	01/31/2012

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