Healthcare Provider Details

I. General information

NPI: 1508778697
Provider Name (Legal Business Name): MR. RICKEY LACKEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21114 ST LEO PLACE 45211
CINCINNATI OH
45211
US

IV. Provider business mailing address

21114 ST LEO PLACE 45211
CINCINNATI OH
45211
US

V. Phone/Fax

Practice location:
  • Phone: 614-704-4135
  • Fax:
Mailing address:
  • Phone: 614-704-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberSV532870
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: