Healthcare Provider Details

I. General information

NPI: 1740836394
Provider Name (Legal Business Name): LACY DILLON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 NE 130TH ST
VANCOUVER WA
98686-2670
US

IV. Provider business mailing address

4001 NE 130TH ST
VANCOUVER WA
98686-2670
US

V. Phone/Fax

Practice location:
  • Phone: 503-333-9294
  • Fax:
Mailing address:
  • Phone: 503-333-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH.61477396
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23030
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: