MEDICARE: MICHAEL J. LACEY MPT

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	225100000X	Physical Therapist	40QA01093000	NJ
2	225100000X	Physical Therapist	5400	SC

General Provider Information

NPI Number	:	1487621173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J. LACEY MPT

Provider Business Mailing Address
First Line	:	825 GOLDEN EYE CT
Second Line	:
City	:	BLYTHEWOOD
State	:	SC
Zip	:	29016-9250
Country	:	US
Telephone Number	:	803-767-9431
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3428
Country	:	US
Telephone Number	:	803-796-8377
Fax Number	:	803-796-8378

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

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	02/12/2008

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