Provider Demographics
NPI:1164649497
Name:LACEY PHYSICAL THERAPY CENTER INCORPORATED
Entity Type:Organization
Organization Name:LACEY PHYSICAL THERAPY CENTER INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:269-668-5930
Mailing Address - Street 1:23211 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9701
Mailing Address - Country:US
Mailing Address - Phone:269-668-5930
Mailing Address - Fax:269-668-5921
Practice Address - Street 1:23211 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9701
Practice Address - Country:US
Practice Address - Phone:269-668-5930
Practice Address - Fax:269-668-5921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI155764OtherGREAT LAKES UNITED HEALTH
MI6430129OtherIBA
MI650H000020OtherBCBS MI
MI7993476OtherAETNA
MIP83205Medicare ID - Type Unspecified