MEDICARE: MR. LARRY CLINTON EATON P.T.

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	225100000X	Physical Therapist	5501001069	MI

General Provider Information

NPI Number	:	1851456867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY CLINTON EATON P.T.

Provider Business Mailing Address
First Line	:	27543 EVELYN AVE
Second Line	:
City	:	BROWNSTOWN TWP
State	:	MI
Zip	:	48183-4859
Country	:	US
Telephone Number	:	734-671-0613
Fax Number	:

Provider Business Practice Location Address
First Line	:	12855 DIX TOLEDO RD
Second Line	:
City	:	SOUTHGATE
State	:	MI
Zip	:	48195-1744
Country	:	US
Telephone Number	:	734-283-2526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/08/2007

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