Provider Demographics
NPI:1083868186
Name:LACKNEY, MICHAEL STEPHEN (CORPSMAN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:LACKNEY
Suffix:
Gender:M
Credentials:CORPSMAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DTHC ARLINGTON NAVY ANNEX CLINIC
Mailing Address - Street 2:F.O.B. #2 ROOM 1323
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20370-0001
Mailing Address - Country:US
Mailing Address - Phone:703-614-2726
Mailing Address - Fax:703-614-1593
Practice Address - Street 1:DTHC ARLINGTON NAVY ANNEX CLINIC
Practice Address - Street 2:F.O.B. #2 ROOM 1323
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20370-0001
Practice Address - Country:US
Practice Address - Phone:703-614-2726
Practice Address - Fax:703-614-1593
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman