Healthcare Provider Details

I. General information

NPI: 1700056926
Provider Name (Legal Business Name): ROBERT E LACEY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9634 S PULASKI RD
OAK LAWN IL
60453-3391
US

IV. Provider business mailing address

10933 S CENTRAL PARK AVE
CHICAGO IL
60655-3304
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-4800
  • Fax:
Mailing address:
  • Phone: 773-779-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: