Healthcare Provider Details

I. General information

NPI: 1821594219
Provider Name (Legal Business Name): ELIJAH AUSTIN LACKEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E HARMONY RD
FORT COLLINS CO
80528-3400
US

IV. Provider business mailing address

2121 E HARMONY RD UNIT 180
FORT COLLINS CO
80528-3401
US

V. Phone/Fax

Practice location:
  • Phone: 970-226-6111
  • Fax: 970-226-6707
Mailing address:
  • Phone: 970-226-6111
  • Fax: 970-226-6707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2022-00049
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: