=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750367264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL W LARY HS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | COMDT (CG-1122), U.S. COAST GUARD 2100 2ND ST SW, SUITE 5314
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20593-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-861-6244
-----------------------------------------------------
Fax | 503-861-6358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1222
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-470-0302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------