Healthcare Provider Details

I. General information

NPI: 1255348090
Provider Name (Legal Business Name): DR. JOHN ANTHONY LACOSTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN ANTHONY LACOSTE D.C, C.C.S.P

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CAMP OPECHEE RD
CENTERVILLE MA
02632-2433
US

IV. Provider business mailing address

PO BOX 355
CENTERVILLE MA
02632
US

V. Phone/Fax

Practice location:
  • Phone: 508-778-2882
  • Fax: 508-534-9621
Mailing address:
  • Phone: 508-778-2882
  • Fax: 508-534-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1302
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: