Provider Demographics
NPI:1023490109
Name:BANKS, LACEMOND
Entity type:Individual
Prefix:
First Name:LACEMOND
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2071
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-2071
Mailing Address - Country:US
Mailing Address - Phone:919-949-5541
Mailing Address - Fax:
Practice Address - Street 1:3904 AIRPORT DR NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-8040
Practice Address - Country:US
Practice Address - Phone:919-949-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
341600000X, 3416L0300X, 343800000X, 343900000X, 347B00000X, 347C00000X
NC465435628343800000X, 347B00000X
NC22070101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347B00000XTransportation ServicesBus
No347C00000XTransportation ServicesPrivate Vehicle