MEDICARE: LULU'S LICE REMOVAL CLINIC, LLC

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1477319143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LULU'S LICE REMOVAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	5263 MILLER BAYOU DR
Second Line	:
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-6224
Country	:	US
Telephone Number	:	727-410-7013
Fax Number	:

Provider Business Practice Location Address
First Line	:	5810 STATE ROAD 54
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-6050
Country	:	US
Telephone Number	:	727-410-7013
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	JOHN E FASSLER
Credential	:	MD
Telephone Number	:	704-909-9414

Provider Enumeration Date	:	02/21/2024
Last Update Date	:	02/21/2024

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