MEDICARE: DR. LACEY RANAY CARDER DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4056	OK

General Provider Information

NPI Number	:	1104197540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LACEY RANAY CARDER DC

Provider Business Mailing Address
First Line	:	1008 S. ROCK ISLAND AVE.
Second Line	:
City	:	EL RENO
State	:	OK
Zip	:	73036-4757
Country	:	US
Telephone Number	:	405-262-0548
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 S ROCK ISLAND AVE
Second Line	:
City	:	EL RENO
State	:	OK
Zip	:	73036-4757
Country	:	US
Telephone Number	:	405-262-0548
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/17/2012

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