Healthcare Provider Details

I. General information

NPI: 1083868186
Provider Name (Legal Business Name): MICHAEL STEPHEN LACKNEY CORPSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DTHC ARLINGTON NAVY ANNEX CLINIC F.O.B. #2 ROOM 1323
WASHINGTON DC
20370-0001
US

IV. Provider business mailing address

DTHC ARLINGTON NAVY ANNEX CLINIC F.O.B. #2 ROOM 1323
WASHINGTON DC
20370-0001
US

V. Phone/Fax

Practice location:
  • Phone: 703-614-2726
  • Fax: 703-614-1593
Mailing address:
  • Phone: 703-614-2726
  • Fax: 703-614-1593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: