Provider Demographics
NPI:1609904663
Name:JOHN LACKEY, INC
Entity Type:Organization
Organization Name:JOHN LACKEY, INC
Other - Org Name:DR. JOHN LACKEY, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-872-6433
Mailing Address - Street 1:702 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-2018
Mailing Address - Country:US
Mailing Address - Phone:304-872-6433
Mailing Address - Fax:304-872-6562
Practice Address - Street 1:702 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE102
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-2018
Practice Address - Country:US
Practice Address - Phone:304-872-6433
Practice Address - Fax:304-872-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV736332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1205951605OtherMEDICARE GROUP PAYER NPI (MEDICAL PRACTICE)
WV1609904663OtherDME SUPPLIER NPI
WV00094926001OtherMEDICAID OPTICAL SUPPLIER NUMBER
WV0257640001OtherMEDICARE DME PTAN (SUPPLIER PTAN)