Healthcare Provider Details

I. General information

NPI: 1285946301
Provider Name (Legal Business Name): LACY CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 KENDRICK RD
MEMPHIS TN
38108-2026
US

IV. Provider business mailing address

3533 KENDRICK RD
MEMPHIS TN
38108-2026
US

V. Phone/Fax

Practice location:
  • Phone: 901-372-3327
  • Fax:
Mailing address:
  • Phone: 901-372-3327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberL000000005891
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License NumberL000000005891
License Number StateTN

VIII. Authorized Official

Name: MR. RANDY BRADFORD
Title or Position: CO-OWNER/PARTNERSHIP
Credential:
Phone: 901-268-7531