Provider Demographics
NPI:1255772646
Name:LACKS, ADAM COY (CSFA, CST)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:COY
Last Name:LACKS
Suffix:
Gender:M
Credentials:CSFA, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 VERMILLION OAK ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-2063
Mailing Address - Country:US
Mailing Address - Phone:713-410-4042
Mailing Address - Fax:
Practice Address - Street 1:2115 VERMILLION OAK ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-2063
Practice Address - Country:US
Practice Address - Phone:713-410-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-13
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant