Healthcare Provider Details

I. General information

NPI: 1164649497
Provider Name (Legal Business Name): LACEY PHYSICAL THERAPY CENTER INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23211 RED ARROW HWY
MATTAWAN MI
49071-9701
US

IV. Provider business mailing address

23211 RED ARROW HWY
MATTAWAN MI
49071-9701
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-5930
  • Fax: 269-668-5921
Mailing address:
  • Phone: 269-668-5930
  • Fax: 269-668-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5501010346
License Number StateMI

VIII. Authorized Official

Name: KEVIN JAMES LACEY
Title or Position: PRESIDENT
Credential: PT, DPT
Phone: 269-668-5930