1609904663 NPI number — JOHN LACKEY, INC

Table of content: (NPI 1609904663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609904663 NPI number — JOHN LACKEY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN LACKEY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. JOHN LACKEY, INC.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609904663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 PROFESSIONAL PARK DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SUMMERSVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26651-2018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-872-6433
Provider Business Mailing Address Fax Number:
304-872-6562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 PROFESSIONAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE102
Provider Business Practice Location Address City Name:
SUMMERSVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26651-2018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-872-6433
Provider Business Practice Location Address Fax Number:
304-872-6562
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LACKEY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-872-6433

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  736 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205951605 . This is a "MEDICARE GROUP PAYER NPI (MEDICAL PRACTICE)" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1609904663 . This is a "DME SUPPLIER NPI" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 00094926001 . This is a "MEDICAID OPTICAL SUPPLIER NUMBER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0257640001 . This is a "MEDICARE DME PTAN (SUPPLIER PTAN)" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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