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General NPI Number Information
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NPI Number | 1609904663
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Entity Type | Organization
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Legal Business Name | JOHN LACKEY, INC
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Dates
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Enumeration Date | 03/01/2007
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 702 PROFESSIONAL PARK DR SUITE102
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-2018
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Country | US
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Telephone | 304-872-6433
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Fax | 304-872-6562
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Provider Business Mailing Address
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Address Line | 702 PROFESSIONAL PARK DR SUITE 102
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-2018
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Country | US
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Telephone | 304-872-6433
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Fax | 304-872-6562
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN LACKEY
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Credential | D.O.
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Telephone | 304-872-6433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 736
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License Number State | WV
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