Healthcare Provider Details

I. General information

NPI: 1437360856
Provider Name (Legal Business Name): ELIZABETH MAE LACEY RESPITE PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 SOUTH 2ND STREET
GLENROCK WY
82637-1986
US

IV. Provider business mailing address

PO BOX 1986
GLENROCK WY
82637-1986
US

V. Phone/Fax

Practice location:
  • Phone: 307-436-2740
  • Fax: 307-436-5350
Mailing address:
  • Phone: 307-436-2760
  • Fax: 307-436-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: