=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205951605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JOHN LACKEY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 02/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 PROFESSIONAL PARK DR SUITE 102
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-6433
-----------------------------------------------------
Fax | 304-872-6562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 PROFESSIONAL PARK DR SUITE 102
-----------------------------------------------------
City | SUMMERSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26651-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-872-6433
-----------------------------------------------------
Fax | 304-872-6562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHYSICIAN
-----------------------------------------------------
Name | JOHN K LACKEY
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 304-872-6433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 736 WV
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------