Provider Demographics
NPI:1952851495
Name:LACK, DEBBIE
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:
Last Name:LACK
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 1:127 AYERS CT
Mailing Address - Street 2:STE F2
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-5152
Mailing Address - Country:US
Mailing Address - Phone:201-471-1034
Mailing Address - Fax:
Practice Address - Street 1:127 AYERS CT
Practice Address - Street 2:STE F2
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-5152
Practice Address - Country:US
Practice Address - Phone:201-471-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJL00521577756692343900000X
NJ821012965374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1303371851Medicare NSC