Provider Demographics
NPI:1982350476
Name:LACKO, MICHAELA (LAC, MSOM)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:LACKO
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S WHEATON AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5207
Mailing Address - Country:US
Mailing Address - Phone:614-419-3704
Mailing Address - Fax:
Practice Address - Street 1:213 S WHEATON AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5207
Practice Address - Country:US
Practice Address - Phone:614-419-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001554171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist