Provider Demographics
NPI:1922662931
Name:BROILS, LACY HATFIELD (ATC)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:HATFIELD
Last Name:BROILS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:NICOLE
Other - Last Name:HATFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:1028 W MINARETS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93650-1065
Mailing Address - Country:US
Mailing Address - Phone:858-204-6667
Mailing Address - Fax:
Practice Address - Street 1:555 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-9098
Practice Address - Country:US
Practice Address - Phone:559-925-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer