Provider Demographics
NPI:1932340668
Name:LACKSON LLC
Entity Type:Organization
Organization Name:LACKSON LLC
Other - Org Name:MATERNAL INSTINCTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-234-1921
Mailing Address - Street 1:1023 YELLOWSTONE AVE
Mailing Address - Street 2:D-1
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4478
Mailing Address - Country:US
Mailing Address - Phone:208-234-8566
Mailing Address - Fax:
Practice Address - Street 1:1023 YELLOWSTONE AVE
Practice Address - Street 2:D-1
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4478
Practice Address - Country:US
Practice Address - Phone:208-234-8566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807536100Medicaid