Provider Demographics
NPI:1013289438
Name:LARRY'S FULL SERVICE SALON
Entity Type:Organization
Organization Name:LARRY'S FULL SERVICE SALON
Other - Org Name:STATE OF MICHIGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:CLAYBAUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:CAREGIVER
Authorized Official - Phone:989-544-2200
Mailing Address - Street 1:10658 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48632-9722
Mailing Address - Country:US
Mailing Address - Phone:989-544-2200
Mailing Address - Fax:
Practice Address - Street 1:10658 ALPINE DR
Practice Address - Street 2:
Practice Address - City:LAKE
Practice Address - State:MI
Practice Address - Zip Code:48632-9722
Practice Address - Country:US
Practice Address - Phone:989-544-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARRY CLAYBAUGH,JR.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1865788385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1865788OtherSTATE OF MICHIGAN HOME HELP CARE PROVIDER#1865788(2003)-PRESENT