Healthcare Provider Details

I. General information

NPI: 1366977027
Provider Name (Legal Business Name): LACEY ROYBAL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1793 13TH ST SE
SALEM OR
97302-2541
US

IV. Provider business mailing address

3600 NW SAMARITAN DR
CORVALLIS OR
97330-3737
US

V. Phone/Fax

Practice location:
  • Phone: 866-599-3376
  • Fax:
Mailing address:
  • Phone: 541-768-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDO188595
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: