Healthcare Provider Details

I. General information

NPI: 1932125333
Provider Name (Legal Business Name): GREGORY TODD LACKEY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 NE 20TH AVE
VANCOUVER WA
98686-2704
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1266
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-5944
  • Fax: 360-574-6430
Mailing address:
  • Phone: 630-468-1824
  • Fax: 630-468-1478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034332
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: