Healthcare Provider Details

I. General information

NPI: 1841026218
Provider Name (Legal Business Name): LACEE JACKSON HAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 HIGHWAY 180 E
SILVER CITY NM
88061-7702
US

IV. Provider business mailing address

5303 50TH ST
LUBBOCK TX
79414-1817
US

V. Phone/Fax

Practice location:
  • Phone: 575-534-9029
  • Fax:
Mailing address:
  • Phone: 806-799-8950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD22002
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: