Provider Demographics
NPI:1760663777
Name:LACEY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:LACEY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-237-1919
Mailing Address - Street 1:PO BOX 2009
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISL ,
Mailing Address - State:SC
Mailing Address - Zip Code:29585-2009
Mailing Address - Country:US
Mailing Address - Phone:843-237-1919
Mailing Address - Fax:843-237-7694
Practice Address - Street 1:9428 OCEAN HWY STE 1
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISL
Practice Address - State:SC
Practice Address - Zip Code:29585-8259
Practice Address - Country:US
Practice Address - Phone:843-237-1919
Practice Address - Fax:843-237-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH304Medicaid