Healthcare Provider Details

I. General information

NPI: 1699001677
Provider Name (Legal Business Name): JAMES RANDALL LACY R.R.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E VETERANS ST
TOMAH WI
54660-3105
US

IV. Provider business mailing address

500 E VETERANS ST
TOMAH WI
54660-3105
US

V. Phone/Fax

Practice location:
  • Phone: 608-372-3971
  • Fax: 608-372-1184
Mailing address:
  • Phone: 608-372-3971
  • Fax: 608-372-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number21833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: