MEDICARE: LARRY EUGENE SKINNER I

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

General Provider Information

NPI Number	:	1932697547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY EUGENE SKINNER I

Provider Business Mailing Address
First Line	:	21283 ORONO RD
Second Line	:
City	:	REED CITY
State	:	MI
Zip	:	49677-8662
Country	:	US
Telephone Number	:	971-235-9255
Fax Number	:

Provider Business Practice Location Address
First Line	:	618A S MITCHELL ST
Second Line	:
City	:	CADILLAC
State	:	MI
Zip	:	49601-2510
Country	:	US
Telephone Number	:	800-252-2065
Fax Number	:

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

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	04/30/2018

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