Provider Demographics
NPI:1255348090
Name:LACOSTE, JOHN ANTHONY
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:LACOSTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:ANTHONY
Other - Last Name:LACOSTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, CCSP
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02632
Mailing Address - Country:US
Mailing Address - Phone:508-778-2882
Mailing Address - Fax:508-534-9621
Practice Address - Street 1:30 CAMP OPECHEE RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-2433
Practice Address - Country:US
Practice Address - Phone:508-778-2882
Practice Address - Fax:508-534-9621
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1302111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU29131Medicare ID - Type Unspecified