Healthcare Provider Details

I. General information

NPI: 1104730993
Provider Name (Legal Business Name): MATEO LACEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 DIXIE ST
LAYTON UT
84041-3305
US

IV. Provider business mailing address

585 DIXIE ST
LAYTON UT
84041-3305
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax: 999-999-9999
Mailing address:
  • Phone: 999-999-9999
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: