Healthcare Provider Details

I. General information

NPI: 1093894164
Provider Name (Legal Business Name): LARA R CLARY-LANTIS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E HURON RIVER DR
YPSILANTI MI
48197-1051
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR PO BOX 0446 - LOBBY J
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8676
  • Fax:
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number5101018066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: