Provider Demographics
NPI:1851970255
Name:BOVA, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W SOUTH BOUNDARY ST BLDG 6
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5235
Mailing Address - Country:US
Mailing Address - Phone:614-339-1649
Mailing Address - Fax:
Practice Address - Street 1:900 W SOUTH BOUNDARY ST BLDG 6
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5235
Practice Address - Country:US
Practice Address - Phone:614-339-1649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid