Healthcare Provider Details

I. General information

NPI: 1376592931
Provider Name (Legal Business Name): LACEY FAMILY MEDICINE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 LACEY RD SUITE 6
FORKED RIVER NJ
08731-1200
US

IV. Provider business mailing address

833 LACEY RD SUITE 6
FORKED RIVER NJ
08731-1200
US

V. Phone/Fax

Practice location:
  • Phone: 609-242-6700
  • Fax: 609-242-6701
Mailing address:
  • Phone: 609-242-6700
  • Fax: 609-242-6701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB06877400
License Number StateNJ

VIII. Authorized Official

Name: KAREN B CRAWFORD
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 732-349-2795