Healthcare Provider Details

I. General information

NPI: 1063324739
Provider Name (Legal Business Name): CALEB LACY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 OAK ST
CONWAY AR
72032-4407
US

IV. Provider business mailing address

197 COPENHAVER TRL
HOT SPRINGS AR
71901-8499
US

V. Phone/Fax

Practice location:
  • Phone: 501-336-8684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPI23756
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: