Healthcare Provider Details

I. General information

NPI: 1235110677
Provider Name (Legal Business Name): LACYONI MORAES, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 COMMERCE DR SUITE A
ABINGDON VA
24211-3876
US

IV. Provider business mailing address

390 COMMERCE DR SUITE A
ABINGDON VA
24211-3876
US

V. Phone/Fax

Practice location:
  • Phone: 276-676-2211
  • Fax: 276-676-0966
Mailing address:
  • Phone: 276-676-2211
  • Fax: 276-676-0966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number0101225620
License Number StateVA

VIII. Authorized Official

Name: LACYONI MORAES
Title or Position: OWNER
Credential: MD
Phone: 276-676-2211