Healthcare Provider Details

I. General information

NPI: 1487091369
Provider Name (Legal Business Name): LACEY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 LACEY RD STE 9
FORKED RIVER NJ
08731-1051
US

IV. Provider business mailing address

1044 LACEY RD STE 9
FORKED RIVER NJ
08731-1051
US

V. Phone/Fax

Practice location:
  • Phone: 609-693-0819
  • Fax: 609-971-0834
Mailing address:
  • Phone: 609-693-0819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB07677400
License Number StateNJ

VIII. Authorized Official

Name: ANN DIPAOLO
Title or Position: OWNER
Credential: DO
Phone: 609-693-0819