Healthcare Provider Details

I. General information

NPI: 1225165012
Provider Name (Legal Business Name): FRANK LACK LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 W TRACY ST
SPRINGFIELD MO
65807-2369
US

IV. Provider business mailing address

1647 W TRACY ST
SPRINGFIELD MO
65807-2369
US

V. Phone/Fax

Practice location:
  • Phone: 417-729-7883
  • Fax:
Mailing address:
  • Phone: 417-729-7883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2001008766
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: