MEDICARE: TIMOTHY SCOTT LACKEY DC

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	111N00000X	Chiropractor	4521	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	060008	OTHER	KS	BCBS

General Provider Information

NPI Number	:	1760482343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY SCOTT LACKEY DC

Provider Business Mailing Address
First Line	:	30 W SHERMAN ST
Second Line	:
City	:	HUTCHINSON
State	:	KS
Zip	:	67501-5428
Country	:	US
Telephone Number	:	620-663-5632
Fax Number	:	620-663-4986

Provider Business Practice Location Address
First Line	:	30 W SHERMAN ST
Second Line	:
City	:	HUTCHINSON
State	:	KS
Zip	:	67501-5428
Country	:	US
Telephone Number	:	620-663-5632
Fax Number	:	620-663-4986

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	10/11/2011

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Directions to “ TIMOTHY SCOTT LACKEY DC” Practice Location

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