Provider Demographics
NPI:1780103812
Name:MEDEARIS, LACEY (LAC)
Entity type:Individual
Prefix:MS
First Name:LACEY
Middle Name:
Last Name:MEDEARIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10556 OLATHE ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-0520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7488 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2702
Practice Address - Country:US
Practice Address - Phone:720-437-0435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-09
Last Update Date:2017-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002235171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist